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

Clinical article

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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 V4 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.

Abbreviations used in this paper: BA = basilar artery; ICA = internal carotid artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery.

Article Information

Current affiliation for Dr. Dashti: Norton Neuroscience Center, Norton Healthcare, Louisville, Kentucky.

Address correspondence to: Felipe C. Albuquerque, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.

Please include this information when citing this paper: published online September 16, 2011; DOI: 10.3171/2011.8.JNS111212.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 3. A and B: Diffusion-weighted axial MR images demonstrate a large right cerebellar infarct and multiple additional embolic infarcts. The fourth ventricle, however, remains patent. C: Simultaneous right ICA and right VA angiograms show a complex dissection of the V4 segment extending into the proximal BA (arrow). D and E: Posteroanterior (D) and lateral (E) right VA angiograms demonstrate dissection and occlusion of the distal artery. The arrows demarcate the anterior spinal artery, which is reconstituted from muscular collaterals from the proximal right VA. F and G: Left VA angiograms demonstrate a dissected segment ending in the posterior inferior cerebellar artery (arrow). H and I: Angiograms showing deployment of 4 stents that reestablished normal vertebrobasilar patency. J: Native fluoroscopic image demonstrates the end markers of the 4 stents. K: Right VA angiogram obtained 24 hours after stent deployment demonstrates in-stent thrombosis. L: Angiogram showing that following angioplasty and thrombolysis, patency is restored. Arrows demarcate residual thrombus within the distal V4 and BAs. M: Postthrombolysis axial MR imaging demonstrates significant enlargement of the cerebellar infarction with effacement of the fourth ventricle. N: Bone window axial CT scan demonstrates a wide craniectomy site. O: Postoperative axial CT scan shows a small amount of clot within the resection cavity. However, the cerebellum is now decompressed and the fourth ventricle is patent. P and Q: Posteroanterior (P) and lateral (Q) right VA angiograms obtained 4 months after discharge demonstrate normal patency of the V4 and basilar arteries throughout the stented segments.

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    Case 6. A and B: Posteroanterior (A) and lateral (B) right ICA angiograms demonstrate a long segment dissection extending from the cervical to the petrous segment (arrows). C and D: Posteroanterior (C) and lateral (D) left ICA angiograms also demonstrate this long segment dissection. Arrows demarcate a thrombus within the dissection. E and F: Posteroanterior (E) and lateral (F) left VA angiograms demonstrate a long segment dissection of the left V3 and V4 segments with occlusion of the vessel just proximal to the BA. G: Perfusion axial CT scan demonstrates decreased flow in the distribution of the right middle cerebral artery, as well as an increased mean transit time (arrows). H and I: Angiograms showing 3 stents placed from the petrous segment down to the proximal cervical right ICA. Arrows demarcate the length of the stented segment. J: Perfusion axial CT scan obtained 2 months after treatment demonstrates normal flow and mean transit time in the territory of the right middle cerebral artery. K and L: Computed tomographic angiography views confirm wide patency of the stented right ICA 8 months after treatment.

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