![]() ![]() The patient was brought to the neurovascular angiography suite and femoral access obtained. Perfusion imaging reflecting rCBV, TTP, rCBF, MTT, and delay (from top-left to bottom-right). CT Stroke Protocol with perfusion imaging demonstrating primary involvement of occipital lobe, cerebellum, and brainstem. A.) 4D CTA demonstrating top of the basilar occusion and poor flow in the right vertebral artery B.) coronal CA demonstrating dissection of verterbral arteries at the C1-C2 level, particularly prominent on the right C.) relative blood volume and D.) corrected relative blood volume.įigure 2. CT Stroke Protocol at time of presentation. The patient received an initial bolus of intravenous tissue plasminogen activator (IV rtPA) at this time and the decision was made to proceed with endovascular intervention given the recent onset of occlusion.įigure 1. This was accompanied by complete occlusion of the basilar tip including the proximal posterior cervical arteries. Upon arrival in the emergency department, a CT stroke protocol was performed which demonstrated bilateral severe distal cervical vertebral artery dissections with acute thrombotic emboli seen in the left cervical vertebral artery (Figures 1 and 2). Mean arterial blood pressure was 80 with palpable femoral pulses at arrival to the emergency department. The patient was intubated on transport and her Glasgow Coma Scale score was 3T prior to arrival. It was reported that the patient was pulseless and apneic for 3 minutes prior to EMS arrival. Emergency Medical Services was called, and cardiopulmonary resuscitation was performed with one round of epinephrine administered. The patient underwent neck manipulation after which she immediately complained of neck pain, diaphoresis, and proceeded to experience cardiac and respiratory arrest. The patient had been at her usual baseline state of health with no significant past medical history prior to visiting the chiropractor for neck adjustment earlier that day for tension like soreness. The patient, a 32-year-old Caucasian woman, presented to the West Virginia University Hospital Emergency Department via Emergency Medical Services. The case therefore satisfies many of the criteria proposed by Hill and used by Tuchin to refute the role of chiropractic manipulation in dissection and stroke. Furthermore, this case presentation demonstrates a likely causal relationship although prior imaging was not available to rule out a pre-existing dissection. This case serves to highlight the potential dangers of chiropractic manipulation and provides a thorough review of the literature relating chiropractic manipulation and stroke. This patient experienced rapid deterioration immediately following manipulation and proceeded to undergo cardiac arrest prior to presentation to the hospital and subsequent death. Herein, we report a case of vertebral artery dissection and subsequent brainstem infarction immediately following chiropractic manipulation in a young female patient. The potential consequence of cervical artery dissection is stroke, which may have a range of consequences with regards to long-term morbidity and mortality. Specifically, epidemiologic associations have been observed between chiropractic maneuvers and cervical artery dissection, although it has been difficult to prove causal relationship. Spinal manipulation, a hallmark practice of chiropractic providers and a practice occasionally utilized by physiotherapists, osteopaths, and physicians, is often viewed as a controversial and potentially dangerous procedure without good evidence supporting its use. Key wordsĬhiropractic manipulation, Vertebral artery dissection, Brainstem infarct, Open communication, Medical clearance Introduction Receiving medical clearance prior to cervical manipulation in potential at risk patients would drastically reduce morbidity and mortality. We utilize this case to highlight the risk associated with cervical manipulation and urge open dialogue between chiropractors and physicians. Although rare, one in 48 chiropractors have experienced such an event. She quickly deteriorated and passed away shortly after arrival to the hospital. In this case report, we highlight a case of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct. Once a dissection has occurred, the risk of thrombus formation, ischemic stroke, paralysis, and even death is drastically increased. The high velocity thrust used in cervical manipulation can produce significant strain on carotid and vertebral vessels. Most patients are never cleared medically for manipulation, which can be devastating for those few who are at increased risk for dissections. Chiropractic cervical manipulation is a common practice utilized around the world. ![]()
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