Vertebral artery dissection in sport: Expert opinion of mechanisms and risk-reduction strategies

Experiential knowledge was collated to improve understanding of the mechanism of vertebral artery dissection (VAD) and inform recommendations for risk-reduction strategies in sport. Fourteen experts from fields of neurology, forensic pathology, biomedical engineering, radiology, physiotherapy, and sport and exercise medicine participated in semi-structured interviews. Experts were asked to provide their hypothesised mechanism of VAD, and suggest strategies to reduce the risk of VAD in non-motorised sports. Experts agreed that there is no single mechanism of VAD. Factors relating to predisposition, susceptibility, and an inciting event exist on a spectrum, as does the severity of the resulting VAD. Particularly concerning inciting events which may occur during sports participation include blunt force impact to the specific area behind and below the ear; and extreme movement of the neck, which may be facilitated by impact to the head or neck. Risk reduction strategies must be feasible within the particular sporting context. Strategies include rules, personal protective equipment, and education to reduce the risk of impact to the head or neck. Education may also serve to improve early recognition of VAD. VAD is a risk (low frequency, severe consequence) in sports in which athletes are exposed to head or neck impact from an object or opponent. Best practice risk management suggests that sports governing bodies should assess VAD risk and consider risk controls.