|Stroke after a visit to the hairdresser |
N Nwokolo, D E Bateman
A visit to the hairdresser is usually regarded as a pleasant social experience. This case illustrates a potential serious hazard of neck extension at the hairdresser.
A 42 year old woman came to the casualty department in September, 1995. The day before she had been to the hairdresser where her neck had been extended over the sink for 5-6 min while her hair was washed. On leaving the hairdressing salon she had difficulty walking, dragging her left leg, but was able to drive home. For the next 2 hr she was unsteady on her feet with increasing numbness of her left hand which could not distinguish between hot and cold. The next day she woke up with numbness around her face and left arm, and slurred speech. Whilst awaiting examination in casualty, her left leg became numb from the foot upwards. Examination showed some sensory loss over face and left arm.
She was reluctant to be admitted to hospital for observation because she had a child to pick up from school. An appointment was made for her to see a neurologist the next day. That evening, however, she fell on her way to the bathroom and could no longer use her left leg. She went to bed and on waking up the next morning still could not stand. She was admitted to hospital.
There was no previous history of migraine, cerebrovascular disease, heart disease, or connective tissue disorder. She was not diabetic. She had taken the oral contraceptive pill many years ago, but was currently on no medication. She did not smoke and drank 14 units of alcohol a week. She had had one normal pregnancy. General examination was normal. Her blood pressure was 100/60 min Hg. She was in sinus rhythm with no heart murmurs or carotid bruits. Neurological examination showed a left faciobrachial paralysis with moderate weakness of the left leg. Pinprick was impaired on the left to a level at T7; joint position sense was absent in the left hand, but present in the foot. Haematological tests, including clotting studies, protein C, and antithrombin III were normal. Connective tissue screen, including anticardiolipin antibody, was negative. Carotid Doppler studies showed dissection of the proximal internal right carotid artery. Computed tomography scan showed patchy infarction in the right middle cerebral artery territory. She was anticoagulated with heparin and warfarin. The strength of the left leg rapidly improved over a few days and the left arm over a few months. A repeat Carotid Doppler study at 4 months showed a normal right internal carotid artery. After 6 months she had made a good recovery apart from residual mild weakness of the left hand and arm with impaired fine movement of the left hand. Warfarin was discontinued.
Carotid artery and vertebral artery dissection are increasingly recognized as a cause of stroke in younger people. Although the first symptoms occurred soon after neck extension, this must have been sufficient to tear the intima, resulting in carotid-artery dissection and a series of subsequent cerebral emboli. The patient had no features of Ehlers Danlos syndrome or other disorder known to predispose to carotid artery dissection.
Washing hair with the neck extended or the chair tilted backwards is a common practice in hairdressing salons, because the position avoids soap getting in the eyes spoiling mascara. This practice is not without risk and hairdressers should be instructed not to over extend the neck and should use the cushion usually provided.
I Bogousslavsky J, Regli F. Ischaemic stroke in adults younger than 20 years of age. Arch Neurol 1987; 44: 479-82.
Department of Neurology, Royal United Hospital, Bath BAI 3NG, UK (D E Bateman)