An Analysis of the Etiology of Cervical Artery Dissections: 1994 to 2003

Vertebral Artery Dissection in a Young Adult: A Case Report

Vertebral artery dissections (VAD) pose a significant risk for strokes, particularly in young adults. This case report details the presentation and management of a 48-year-old patient who was diagnosed with an extracranial VAD following cervical spine manipulation (CSM). The patient's symptoms included acute right-sided ataxia, giddiness, vertigo, nausea, vomiting, and persistent pain behind the right ear, prompting immediate evaluation. After ruling out acute intracerebral hemorrhages, a computed tomography angiogram (CTA) of the head and neck identified a severe narrowing of the right distal vertebral artery with a string sign at the level of the right C1 loop (V3 segment), indicating an extracranial VAD. This finding was further supported when ultrasound (US) imaging revealed a high resistance flow pattern in the right distal vertebral artery. Furthermore, T2 and diffusion-weighted magnetic resonance imaging (MRI) confirmed a 1.8 cm VAD/hematoma and a 1.4 cm acute/subacute infarct in the right posterior inferior cerebellar artery (PICA) territory. This research accentuates the importance of recognizing and addressing that neck pain can be a symptom of musculoskeletal dysfunction or could have neurovascular origins. In this case, the patient's neck pain may have been musculoskeletal or could have been due to a previous dissection. Thus, differentiation should be considered before cervical spine manipulation.

The association between cervical artery dissection and spinal manipulation among US adults

PURPOSE

Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults.

METHODS

Through analysis of health claims data, we employed a case-control study with matched controls, a case-control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6-7 months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group.

RESULTS

We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6 months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week.

CONCLUSION

Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.

Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis

BACKGROUND

Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation.

METHODS

We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007-2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6-7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event.

RESULTS

The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar.

CONCLUSION

Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.

Internal carotid artery dissection following self-manipulation: A case report

Arterial dissections are a common cause of stroke in young patients. Dissection occurs when the structure of the arterial wall is compromised, allowing blood to collect between layers as an intramural hematoma. Symptoms of cervical artery dissection may include pain, Horner syndrome, cranial and cervical neuropathies, and pulsatile tinnitus. Treatment varies depending on the severity of symptoms but generally includes anticoagulation with surgical therapy reserved for patients with progressive neurologic symptoms or symptom recurrence while on maximum medical therapy. Here, we present the case of a traumatic internal carotid artery dissection with significant narrowing of the artery in a healthy 26-year-old female after self-manipulation of the neck. She developed Horner syndrome secondary to her dissection. Our patient was initially treated with anticoagulation and transitioned to clopidogrel and atorvastatin for outpatient treatment. Six-month follow-up computed tomography angiography showed complete resolution of her dissection. She had overall significant improvement in her symptoms with only mild residual ptosis on the follow-up examination. While the presentation of a patient with neurologic sequelae from a cervical artery dissection causing stroke is a well-known phenomenon, the mechanical cause in this particular case is rare. There have been several case reports in the literature detailing cervical artery dissections following cervical manipulative therapy by trained professionals (i.e. chiropractors, physical therapists, osteopathic physicians) but none occurring from self-manipulation of the neck. This case report details successful treatment of a rare case of internal carotid dissection following self-manipulation with appropriate medical therapy.

Spine artery dissection as another puzzle of Covid-19 (Clinical case)

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Vertebral artery dissection in term pregnancy after cervical spine manipulation: a case report and review the literature

BACKGROUND

Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, we focused on the differential diagnosis, reviewing the available evidence.

CASE PRESENTATION

A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section.

CONCLUSION

Vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.

What are the risks of manual treatment of the spine? A scoping review for clinicians

Background

Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research.

Method

A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points.

Results

Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk.

Conclusion

Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.

Seasonal variation in cervical artery dissection in the Hunter New England region, New South Wales, Australia: A retrospective cohort study

BACKGROUND

Cervical artery dissection (CAD) is a leading cause of ischemic stroke among middle aged adults, yet the aetiology remains poorly understood. There are reports from colder northern hemisphere sites of a seasonal pattern in the incidence of CAD. Seasonality may suggest some transient putative pro-inflammatory mechanism but it is unknown whether this also exists in temperate climates.

AIMS

To investigate the seasonal variation in incidence of CAD in the xx Region, Australia, and to compare seasonal incidence and selected clinical features between cases of carotid and vertebral artery dissection.

METHODS

This retrospective observational study investigated seasonal variation in CAD from a regional stroke register between 2006 and 2014. Clinical features and site of dissection were dichotomized into autumn-winter and spring-summer groups and compared with Chi² analysis.

RESULTS

61 CAD events were identified. A strong trend was identified for CAD to occur more frequently in autumn-winter compared to spring-summer (38, 62.30% vs. 23, 37.70%; p = 0.054). Males were significantly more likely to present with vertebral artery dissection (VAD) than females (27, 73.0% vs 10, 41.7%; p = 0.014). A history of mild trauma was more common in VAD than internal carotid artery dissection (ICAD) (14, 41.2% vs 3, 13.0%; p = 0.023). Cases of VAD were more likely to have had an elevated white cell count than ICAD (16, 47.1% vs 5, 20.8%; p = 0.041).

CONCLUSIONS

The findings suggest seasonal variation in the CAD incidence in a temperate region of Australia. Clinicians should be vigilant for CAD or risk of CAD during the colder months.

Multiple Spontaneous Intracranial-Extracranial Arterial Dissections in a Patient with Osteogenesis Imperfecta

A 40-year-old male with osteogenesis imperfecta (OI) was admitted to the hospital with an acute right monoparesis. Diffusion-weighted MRI showed infarction in the territory of the left anterior cerebral artery (ACA) and in the left posterior cerebral artery (PCA). In his vascular imaging, occlusion of the left vertebral artery (VA) starting from V2 segment was consistent with dissection and pseudoaneurysm in the right ACA. We presented this case because of the presence of spontaneous and simultaneous occurrence of both intracranial and extracranial arterial dissections in OI.

Headache in pregnancy: an approach to emergency department evaluation and management

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy

Recognition of spontaneous vertebral artery dissection preempting spinal manipulative therapy: a patient presenting with neck pain and headache for chiropractic care

OBJECTIVE

The purpose of this case report is to describe a patient who presented to a chiropractic physician for evaluation and treatment of neck pain and headache.

CLINICAL FEATURES

A 45-year-old otherwise healthy female presented for evaluation and treatment of neck pain and headache. Within minutes, non-specific musculoskeletal symptoms progressed to neurological deficits, including limb ataxia and cognitive disturbances. Suspicion was raised for cerebrovascular ischemia and emergent referral was initiated.

INTERVENTION AND OUTCOME

Paramedics were immediately summoned and the patient was transported to a local hospital with a working diagnosis of acute cerebrovascular ischemia. Multiplanar computed tomographic and magnetic resonance imaging with contrast revealed vertebral artery dissection of the V2 segment in the right vertebral artery. Anticoagulation therapy was administered and the patient was discharged without complications after 5 days in the hospital.

CONCLUSION

This case highlights the potential for patients with vertebral artery dissection to present with nonspecific musculoskeletal complaints. Neurological symptoms may not manifest initially, but their sudden onset indicates the possibility of an ischemic cerebrovascular event. We suggest that early recognition and emergent referral for this patient avoided potential exacerbation of an evolving pre-existing condition and resulted in timely anticoagulation treatment.

Quantifying strain in the vertebral artery with simultaneous motion analysis of the head and neck: a preliminary investigation

BACKGROUND

Spontaneous vertebral artery dissection has significant mortality and morbidity among young adults. Unfortunately, causal mechanisms remain unclear. The purpose of this study was to quantify mechanical strain in the vertebral artery while simultaneously capturing motion analysis data during passive movements of the head and neck relative to the trunk during spinal manipulation and cardinal planes of motion.

METHODS

Eight piezoelectric crystals (four per vertebral artery) were sutured into the lumen of the left and right vertebral arteries of 3 cadaveric specimens. Strain was then calculated as changes in length between neighboring crystals from a neutral head/neck reference position using ultrasound pulses. Simultaneously, passive motion of the head and neck on the trunk was captured using eight infrared cameras. The instantaneous strain arising in the vertebral artery was correlated with the relative changes in head position.

FINDINGS

Strain in the contralateral vertebral artery during passive flexion-rotation compared to that of extension-rotation is variable ([df=32]: -0.61<r<0.55). Peak strain does not coincide with peak angular displacement during spinal manipulation and cardinal planes of motion. Axial rotation displayed the greatest amount of strain. The greatest amount of strain achieved during spinal manipulation was comparably lower than strains achieved during passive end range motions and previously reported failure limits.

INTERPRETATION

The results of this study suggest that vertebral artery strains during head movements including spinal manipulation, do not exceed published failure strains. This study provides new evidence that peak strain in the vertebral artery may not occur at the end range of motion, but rather at some intermediate point during the head and neck motion.

Traumatic vertebral artery injury: proposal for classification of the severity of trauma and likelihood of fatal outcome

Vertebral artery injury (VAI) occurs after (blunt) trauma as well as spontaneously. The risk of incurring VAI from a blunt trauma probably parallels the severity of trauma, often referred to as major- and minor-trauma. However, the literature does not provide concrete definitions of these terms. This study aims to define minor- and major-trauma and to analyze the likelihood of fatal outcome in VAI. For this purpose, classification criteria of major- and minor-trauma were developed and a PubMed database search was performed for articles on VAI published prior to 2013. The definitions of minor- and major-trauma, derived mainly from radiological screening criteria in cervical spine injury and based on the mechanism leading to the injury, were used in the analysis of the literature. The search produced 241 VAI cases with sufficiently detailed data for the comparison of major-trauma (52 cases, 50 lethal), minor-trauma (8 cases, none lethal), and no-trauma (182 cases, 69 lethal). The numbers of lethal cases in the total study population and subgroups differed significantly between the groups (Fisher's exact test) and the likelihood ratios (LRs) of lethal outcome were substantially higher in the major-trauma group compared to the other groups. The highly significant p values show that the proposed criteria differentiate between trauma types with regard to fatal outcome. The presented results can assist in the evaluation of forensic cases of VAI.

Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association

PURPOSE

Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

RESULTS

Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

CONCLUSIONS

CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

Traumatic dissection of the internal carotid artery: simultaneous infarct of optic nerve and brain

KEY CLINICAL MESSAGE

Traumatic intracranial internal carotid artery dissection is a rare but significant cause of stroke in patients in their forties, leading to high morbidity and mortality. Simultaneous ischemic stroke and optic nerve infarction can occur. Clinical suspicion of dissection is determining in the acute management.

Changes in vertebral artery blood flow following various head positions and cervical spine manipulation

OBJECTIVE

The objective of the study was to investigate the cerebrovascular hemodynamic response of cervical spine positions including rotation and cervical spine manipulation in vivo using magnetic resonance imaging technology on the vertebral artery (VA).

METHODS

This pilot study was conducted as a blinded examiner cohort with 4 randomized clinical tasks. Ten healthy male participants aged 24 to 30 years (mean, 26.8 years) volunteered to participate in the study. None of the participants had a history of disabling neck, arm, or headache pain within the last 6 months. They did not have any current or history of neurologic symptoms. In a neutral head position, physiologic measures of VA blood flow and velocity at the C1-2 spinal level were obtained using phase-contrast magnetic resonance imaging after 3 different head positions and a chiropractic upper cervical spinal manipulation. A total of 30 flow-encoded phase-contrast images were collected over the cardiac cycle, in each of the 4 conditions, and were used to provide a blood flow profile for one complete cardiac cycle. Differences between flow (in milliliters per second) and velocity (in centimeters per second) variables were evaluated using repeated-measures analysis of variance.

RESULTS

The side-to-side difference between ipsilateral and contralateral VA velocities was not significant for either velocities (P = .14) or flows (P = .19) throughout the conditions. There were no other interactions or trends toward a difference for any of the other blood flow or velocity variables.

CONCLUSIONS

There were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations.

Risk factors, radiological features, and infarct topography of craniocervical arterial dissection

BACKGROUND

Craniocervical arterial dissection is a common cause of ischemic stroke in the young to middle-aged population. There have been a number of previous studies where radiological features have been described but few with detailed mapping of infarct topography and none where these features have been related to the reported risk factors.

AIMS

The aims of this study were to describe the radiological characteristics of dissection patients ≤55 years and relate these to reported risk factors.

METHODS

Craniocervical arterial dissection cases ≤55 years, and age- and gender-matched controls were identified from a medical records database between 1998 and 2009. Control cases had stroke from another cause than dissection. Records and radiology were reviewed.

RESULTS

Thirty-six radiologically confirmed dissection cases [20 (56%) vertebral artery, 16 (44%) internal carotid], and 43 controls were identified. Dissections were extracranial with intracranial extension in 10 (28%) cases. Infarction was demonstrated in 22 (61%) dissection cases. The most common wall deficit identified was an intimal flap. Twenty-three (64%) dissection cases had a recent history of neck trauma (P > 0·000) and 13 (36%) had vascular variants (P = 0·013).

CONCLUSION

Craniocervical arterial dissection cases, particularly vertebral artery, were more likely to have a history of neck trauma. Dissections were most commonly extracranial, in the upper cervical region, with intracranial extension in 28%. Dissection cases with trauma more commonly had a dissection flap and evidence of infarction in the lateral medulla, anterior or posterior inferior cerebellar artery territory. Close inspection of the V3 segment of the vertebral or skull base for internal carotid artery may be warranted with a history of neck trauma.

Risk factors and clinical presentation of craniocervical arterial dissection: a prospective study

Background

Craniocervical arterial dissection is a major cause of ischaemic stroke in young adults. The pathogenesis is not fully understood but is thought to be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. Intrinsic susceptibility is thought to be a generalised arteriopathy, vascular anomaly or genetic predisposition. Proposed extrinsic factors include recent viral infection and minor mechanical trauma to the neck, including neck manipulation, which has raised concerns amongst manual practitioners in particular as to the appropriate screening of patients and avoidance of more vigorous therapeutic techniques. The presenting features of dissection may mimic a musculoskeletal presentation, creating a diagnostic dilemma for primary care practitioners. Early recognition is critical so that appropriate management can be commenced.

The aims of this study are to prospectively investigate young patients ≤55 years admitted to hospital with radiologically diagnosed craniocervical arterial dissection compared to matched controls with stroke but not dissection, to identify risk factors and early presenting clinical features, so these may be more readily identified by primary care practitioners.

Methods

Patients ≤ 55 years presenting to hospital with craniocervical arterial dissection and controls will have their medical records reviewed and be interviewed and questioned about possible risk factors, preceding events to admission such as recent neck trauma, and presenting clinical features including any preceding transient ischaemic features. Clinical assessment will include a connective tissue screening examination to identify subclinical connective tissue disorders. Radiology and blood screening will be reviewed for typical features and inflammatory markers. Functional outcome will be reviewed to determine the burden of the stroke.

Discussion

This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.

Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management

OBJECT

Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era.

METHODS

A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up.

RESULTS

Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up.

CONCLUSIONS

Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

The etiology of cervical artery dissection

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.

Headache attributed to carotid or vertebral artery pain

Headache or pain in the face or neck attributed to the carotid or vertebral artery was not recognized as a special type of pain until the concept of carotidynia occurred in the 1960s. Carotidynia has long been assumed as an entity until modern imaging techniques showed that pain localized in the carotid region could most often be related to injury of the artery or other symptomatic causes. These causes include headache due to arterial dissection, which has been described as a true pain originating from the vessel structure itself and which has also been attributed to a comorbidity of migraine and cervical artery dissection. Furthermore, headache starting after endarterectomy, carotid angioplasty headache, headache attributed to intracranial endovascular procedures, and angiography headache have been listed among the headache and pain syndromes due to changes of the cervical arteries. It is still not clarified whether carotidynia is a specific idiopathic disease or whether the previous descriptions of carotidynia just resembled symptomatic causes of carotid pain.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

OBJECTIVE

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery.

SUMMARY AND BACKGROUND DATA

Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible.

CLINICAL REPORT

A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma.

CONCLUSION

Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Internal carotid artery dissection: an unusual cause of postpartum headache

We report a case of postpartum headache caused by internal carotid artery dissection in a 36-year-old woman following uneventful epidural analgesia for spontaneous labor and vaginal delivery. Cervicocerebral arterial dissection requires rapid diagnosis and anticoagulation to prevent thrombus formation and to avoid secondary cerebral thromboembolism. Fortunately, our patient suffered ischemic symptoms, but no permanent neurologic deficit. Anesthesiologists should consider carotid artery dissection in the differential diagnosis of postpartum headache.

Intracranial Hypotension Causing Headache and Neck Pain: A Case Study

OBJECTIVE

The purpose of this study is to discuss the presentation, examination, diagnosis, and treatment of a case of intracranial hypotension presenting to a chiropractic office as acute severe headache and neck pain.

CLINICAL FEATURES

Flexion injury during a weight lift resulted in a severe postural headache and upper cervical spine pain in a 51-year-old man. The patient presented with unusual symptoms, but normal palpatory findings, and a lack of postural distortion.

INTERVENTION AND OUTCOME

Based on the history, symptoms, and examination findings, the patient was referred for an emergency medical evaluation. A diagnosis of intracranial hypotension was made, and a dural leak was confirmed by radioisotope cisternography. The patient made a complete recovery.

CONCLUSIONS

Intracranial hypotension can cause headache and neck pain that may appear to be musculoskeletal in nature. The key symptom is the orthostatic nature of the headache.

Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature

Background

The misuse of the title 'chiropractor' and term 'chiropractic manipulation', in relation to injury associated with cervical spine manipulation, have previously been reported in the peer-reviewed literature.

The objectives of this study were to -

1) Prospectively monitor the peer-reviewed literature for papers reporting an association between chiropractic, or chiropractic manipulation, and injury;

2) Contact lead authors of papers that report such an association in order to determine the basis upon which the title 'chiropractor' and/or term 'chiropractic manipulation' was used;

3) Document the outcome of submission of letters to the editors of journals wherein the title 'chiropractor', and/or term 'chiropractic manipulation', had been misused and resulted in the over-reporting of chiropractic induced injury.

Methods

One electronic database (PubMed) was monitored prospectively, via monthly PubMed searches, during a 12 month period (June 2003 to May 2004). Once relevant papers were located, they were reviewed. If the qualifications and/or profession of the care provider/s were not apparent, an attempt was made to confirm them via direct e-mail communication with the principal researcher of each respective paper. A letter was then sent to the editor of each involved journal.

Results

A total of twenty four different cases, spread across six separate publications, were located via the monthly PubMed searches. All twenty four cases took place in one of two European countries.

The six publications consisted of four case reports, each containing one patient, one case series, involving twenty relevant cases, and a secondary report that pertained to one of the four case reports. In each of the six publications the authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury.

In two of the four case reports contact with the principal researcher revealed that the care provider was not a chiropractor, as defined by the World Federation of Chiropractic. The authors of the other two case reports did not respond to my communications. In the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training. The author of the secondary report, a British Medical Journal editor, conceded that he had misused the title chiropractor. Letters to editors were accepted and published by all four journals to which they were sent. To date one of the four journals has published a correction.

Conclusion

The results of this year-long prospective review suggests that the words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing 'letters to editors', and to a lesser extent 'corrections', when authors had inappropriately used the title 'chiropractor' and/or term 'chiropractic manipulation'.