Bilateral Vertebral Artery (VA) Dissection Causing Acute Ischemic Stroke Following High Velocity Cervical Manipulation

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Arterial dissections are a common cause of stroke in the young but may occur at any age. Dissection occurs when the structural integrity of the arterial wall is compromised, allowing blood to collect between layers as an intramural hematoma. A 35y.o. healthy female who developed acute onset neck pain associated with right (R) arm and R face numbness, severe dizziness, and diplopia immediately following cervical manipulation at her chiropractor's office. She was rushed to the emergency department, where her Initial physical exam was notable for R-sided facial droop, exotropia, hoarseness, decreased sensation, and numbness in the R face and R arm. Initial CT and CTA head were unremarkable. Her CTA neck showed bilateral VA dissections involving V1, V2, and V3 segments of the R VA and V2 segment of the L VA. Interventional radiology team was consulted and recommended medical management. She received tPA in the ER and was transferred to the ICU for post-tPA monitoring. Deficits gradually improved. 2D echo did show a PFO, which was believed to be an incidental finding. MRI/MRA brain showed an acute infarct at the right posterolateral medulla compatible with R V3 and V4 segmental VA dissection. Her stroke was also complicated by cervicalgia and intermittent RUE paresthesia. It was concluded that her stroke was secondary to high-velocity cervical manipulations. She has no history or physical findings suggestive of a connective tissue disorder like Marfan Syndrome (MS) or Ehlers-Danlos syndrome (EDS). Pt was discharged in stable conditions. VA dissections are known complications of spinal manipulation procedures. The exact incidence of this complication is unknown. These events occur at an average age of 40 years and are more common in patients with connective tissue diseases. They are most reported following neck trauma or manipulation, such as motor vehicle accidents, chiropractic maneuvers, yoga, coughing, and ceiling painting. Presently, no screening modality is available for the identification of patients at risk for cerebrovascular events following spinal manipulation. Patients with an increased risk of stroke due to atherosclerotic vascular disease, such as those with hypertension or diabetes mellitus, do not appear to have an increased risk for stroke after spinal manipulation. Also, attempts to assess VA patency prior to manipulation have not been successful in identifying patients at increased risk. The risk for stroke following neck trauma/manipulation appears to be inherently dependent on the manipulation technique and the rotational forces applied to the neck.

Volume

209

Issue

Suppl

First Page

A5605

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A5605

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