Abstract 1122‐000200: Chiropractor Manipulation Leading to Bilateral Vertebral Artery Dissection and Acute Ischemic Stroke

Introduction : Traumatic cervical artery dissection is one of the leading causes of stroke in patients under the age of 45. Recent chiropractic neck manipulation is associated with risk of vertebral artery dissection (VAD). The V3 segment of the vertebral artery is highly susceptible to the bending forces during forced manipulation leading to intimal damage. Methods : N/A Results : This is a case presentation of a 44 year old male who was transferred from another emergency department for left homonymous inferior quadrantanopia noted on an optometrist visit. He reported sudden onset left homonymous hemianopia after receiving a high velocity cervical spine adjustment at a chiropractor appointment for chronic neck pain a few days prior. CT angiogram of the head and neck revealed bilateral vertebral artery dissection at left V2 and right V3 segments. MRI brain confirmed an acute infract in the right medial occipital lobe. His right PCA stroke was likely embolic from the injured right V3 but possibly from the left V2 as well. As the patient reported progression from a homonymous hemianopia to a quadrantanopia, he likely had a migrating embolus. Conclusions : Arterial dissection accounts for about 2% of all ischemic strokes, but may be between 8–25% in patients less than 45 years old. VAD can result from trauma of varying severities ‐ from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing. It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. In the United States, patients who have multiple chronic conditions are reporting higher use of complementary or alternative medicine, including chiropractic manipulation. Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes. In addition, vertebral artery dissection symptoms can be subtle and patients presenting to chiropractors may have distracting pain masking their deficits. Evaluating for appropriateness of cervical manipulation in high‐risk patients and detecting early clinical signs of VAD by chiropractors can be beneficial in preventing acute ischemic strokes in young patients.

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Carotid and Vertebral Artery Dissection Syndromes.

Blood ◽

10.1182/blood.v106.11.4145.4145 ◽

2005 ◽

Vol 106 (11) ◽

pp. 4145-4145

Author(s):

Beatriz Grand ◽

Jorge Solimano ◽

Adriana Ventura ◽

Ernesto Quiroga Micheo ◽

Dardo Riveros

Keyword(s):

Vertebral Artery ◽

Clinical Presentation ◽

Oral Anticoagulants ◽

Vertebral Artery Dissection ◽

Clinical Signs ◽

Young Patients ◽

Complete Recovery ◽

Artery Dissection ◽

Hemorrhagic Complication ◽

Progressing Stroke

Abstract Objetives: To describe the clinical presentation, diagnosis and treatment of patients with carotid and vertebral artery dissection (CAD, VAD). Design: Retrospective, observational Patients and methods: Clinical recording were evaluated from 1996 to 2005; 6 patients (3 women, 3 men, mean age 37 years) with CAD (3) and VAD (3) were referred to our hematology unit. Clinical presentation: progressing stroke 4/6 and transient ischemic attack (TIA) 2/6; warning sings and symptoms preceding the onset of stroke in 80%. Vascular risk factors included smoking and hypertension; associated features were headache, visual symptoms and Horner’s syndrome; Predisposing factors as physical exercise and trauma were found in 4/6. One patient was at 20 weeks of pregnancy. Diagnosis: Diagnostic tests included: Doppler ultrasound, magnetic resonance imaging (MRI) and angiography (MRA). On admission angiographic studies showed occlusion or stenoses of dissected arteries. Treatment: Anticoagulation with heparin or low molecular weight heparin followed by oral anticoagulants. Outcome: No hemorrhagic complication, no recurrence, complete recovery in 5 patients and mild dysarthria in one. Conclusion: TIA and progressing stroke in young patients are presenting features of CAD and VAD. The diagnosis is based on clinical signs and confirming angiographic investigation. Our experience shows that anticoagulation is the treatment of choice, although controlled studies to show their effectiveness are lacking.

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Prevalence of Cervical Artery Dissection among Hospitalized Patients with Stroke by Age in a Nationally Representative Sample from the United States

Neurology ◽

10.1212/wnl.0000000000011420 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011420

Author(s):

Yahya B. Atalay ◽

Pirouz Piran ◽

Abhinaba Chatterjee ◽

Santosh Murthy ◽

Babak B. Navi ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Representative Sample ◽

Age Groups ◽

Vertebral Artery Dissection ◽

The United States ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cervical Artery ◽

Nationally Representative

Objective:To test the hypothesis that the prevalence of cervical artery dissection remains constant across age groups, we evaluated the relationship between age and cervical artery dissection in patients with stroke using a Nationally Representative Sample from the United States.Methods:We used inpatient claims data included in the 2012-2015 releases of the National Inpatient Sample (NIS). We used validated ICD-9-CM codes to identify adults hospitalized with ischemic stroke and a concomitant diagnosis of carotid- or vertebral-artery dissection. Survey weights provided by the NIS and population estimates from the U.S. census were used to calculate nationally representative estimates. The chi-square test for trend was used to compare the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Poisson regression and the Wald test for trend were used to evaluate whether the prevalence of hospitalizations for stroke and concomitant dissection per million person-years varied by age groups.Results:There were 17,320 (95% confidence interval [CI], 15,614-19,026) hospitalizations involving ischemic stroke and a concomitant dissection. The prevalence of dissection among stroke hospitalizations decreased across 10-year age groups from 7.2% (95% CI, 6.2%-8.1%) among persons younger than age 30 years to 0.2% (95% CI, 0.1%-0.2%) among persons older than age 80 years (P value for trend <0.001). However, the prevalence of hospitalizations for stroke and concomitant dissection increased from 5.4 (95% CI, 4.6-6.2) hospitalizations per million person-years among adults younger than age 30 to 24.4 (95% CI, 21.0-27.9) hospitalizations per million person-years among adults older than age 80 (P value for trend <0.01).Conclusions:In a nationally representative sample, the prevalence of hospitalizations for dissection-related stroke increased with age.

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Vertebral Artery Dissection Related to Amphetamine Abuse – A Case Report

Journal of Central Nervous System Disease ◽

10.1177/1179573520939340 ◽

2020 ◽

Vol 12 ◽

pp. 117957352093934

Author(s):

Frederik Winsløw ◽

Nadja Skadkær Hansen ◽

Michael Broksgaard Jensen

Keyword(s):

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cerebral Magnetic Resonance Imaging ◽

Amphetamine Abuse ◽

Increased Risk ◽

Stroke In The Young ◽

Computed Tomography Angiogram ◽

Neck Vessels

We report the case of a 37-year-old male patient with chronic amphetamine abuse who presented with vertebral artery dissection. Prior to presentation, he had increased the consumption of amphetamine from 5 times a year to once every week and had used amphetamine on the day of presentation. He attended with neck pain, vertigo and coordinating difficulties of his left arm. Computed tomography angiogram of the neck vessels showed a left vertebral stenosis and cerebral magnetic resonance imaging showed a left vertebral pseudolumen and a medullary stroke. Cervical artery dissection is a major cause of stroke in the young. To the authors’ knowledge, this is the second reported case of vertebral artery dissection in a patient with amphetamine abuse. Amphetamine might contribute to an increased risk of vertebral artery dissection through its vasculopathic properties although more data are needed to establish a causal relationship.

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Unilateral and bilateral vertebral artery dissection following motor vehicle injury—Two cases and a mini-review

International Journal of Angiology ◽

10.1007/s00547-005-2042-x ◽

2011 ◽

Vol 14 (04) ◽

pp. 242-248

Author(s):

Christina Mandila ◽

Georgios Koukoulitsios ◽

Georgios Stathopoulos ◽

Ioannis Karampelas ◽

Georgios Karydas ◽

...

Keyword(s):

Vertebral Artery ◽

Motor Vehicle ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Motor Vehicle Injury

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Delayed vertebral artery dissection after mild trauma in a motor vehicle collision

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2020.11.028 ◽

2020 ◽

Author(s):

Gregory Kacprzynski ◽

Joshua Bucher

Keyword(s):

Vertebral Artery ◽

Motor Vehicle ◽

Vertebral Artery Dissection ◽

Motor Vehicle Collision ◽

Artery Dissection ◽

Vehicle Collision

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CAROTID AND VERTEBRAL ARTERY DISSECTION DUE TO DECELERATION INJURY IN A MOTOR VEHICLE CRASH

Journal of Trauma and Acute Care Surgery ◽

10.1097/00005373-200110000-00035 ◽

2001 ◽

Vol 51 (4) ◽

pp. 818 ◽

Cited By ~ 3

Author(s):

Nimesh N. Patel ◽

Stewart C. Wang

Keyword(s):

Vertebral Artery ◽

Motor Vehicle ◽

Vertebral Artery Dissection ◽

Motor Vehicle Crash ◽

Artery Dissection ◽

Vehicle Crash

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Internal carotid and vertebral artery dissection: morphology, pathophysiology and provoking factors

Bulletin of Russian State Medical University ◽

10.24075/brsmu.2019.064 ◽

2019 ◽

pp. 72-78

Author(s):

LA Kalashnikova ◽

TS Gulevskaya ◽

AV Sakharova ◽

RP Chaykovskaya ◽

MV Gubanova ◽

...

Keyword(s):

Connective Tissue ◽

Vertebral Artery ◽

Arterial Wall ◽

Internal Carotid ◽

Vertebral Artery Dissection ◽

Clinical Signs ◽

Tissue Inhibitor Of Metalloproteinase ◽

Arterial Dissection ◽

Artery Dissection ◽

Elastic Membrane

The causes of internal carotid artery (ICA) and vertebral artery (VA) dissection, as well as its provoking factors, remain understudied. The aim of this paper was to explore morphological changes in the ICA/VA walls, factors provoking dissection, clinical signs and biomarkers of connective tissue (CT) damage. A total of 271 patients were examined, of whom 54% were women. The mean age of the participants was 37.0 ± 10 years. Clinical signs and biomarkers of CT damage (matrix metalloproteinase 9, tissue inhibitor of metalloproteinase 1, hydroxyproline, sulphated glycosaminoglycans) were analyzed in 82 patients and 40 healthy volunteers. Histologic examination of dissected and seemingly intact arteries conducted in 5 cases revealed signs of arterial wall dysplasia similar to those characteristics of fibromuscular dysplasia: thinning and splitting of the internal elastic membrane, areas of fibrosis, irregular orientation of myocytes, and their necrosis in the tunica media. Clinical signs and biomarkers of CT dysplasia (CTD) were more pronounced in patients with arterial dissection than in the controls. The major provoking factors were head turns and physical activity (42%), minor head injury (10%), and acute respiratory infection in the month preceding arterial dissection (14%). We conclude that arterial wall dysplasia is a predisposing factor for ICA/VA dissection, both spontaneous and provoked. The analysis of CTD biomarkers and clinical signs suggests connective tissue pathology in patients with ICA/VA dissection.

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Stroke prevention by endovascular treatment of carotid and vertebral artery dissections

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012565 ◽

2016 ◽

Vol 9 (10) ◽

pp. 952-957 ◽

Cited By ~ 10

Author(s):

Karam Moon ◽

Felipe C Albuquerque ◽

Tyler Cole ◽

Bradley A Gross ◽

Cameron G McDougall

Keyword(s):

Endovascular Treatment ◽

Vertebral Artery ◽

Demographic Data ◽

Vertebral Artery Dissection ◽

Endovascular Intervention ◽

Artery Dissection ◽

Parent Artery ◽

Indications For Treatment ◽

Patient Reported

IntroductionEndovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances.ObjectiveTo review our institutional experience with endovascular treatment of cervical dissections over the past 20 years to examine indications for treatment, interventional methods, and outcomes.MethodsRetrospective review of a prospectively maintained database to identify patients with extracranial dissection who underwent endovascular intervention between January 1996 and January 2016. Demographic data and details of procedures, outcomes, and complications were extracted.ResultsOf 116 patients [93 CAD, 23 VAD; mean age 44.9 years (range 5–76 years)], 104 underwent stent placement; 11, coil occlusion of the parent artery; and 1, stenting with contralateral vessel occlusion. The cohorts were well matched for age, sex, dissection etiology, and admission and follow-up modified Rankin Scale (mRS) scores. Patients with CAD had significantly more stent placements (p<0.001), failure of medical therapy (p=0.004), and interventions for enlarging pseudoaneurysms (p=0.01) or thromboembolic events (p=0.004). Patients with VAD had significantly more interventions for traumatic occlusion with recanalization (p<0.001). Dissections were spontaneous (n=67), traumatic (n=36), or iatrogenic (n=13). Traumatic dissections in patients with CAD were associated with poor admission mRS scores (p=0.01). Six of 67 (9.0%) patients with spontaneous dissection reported recent chiropractic manipulation. Mean follow-up was 3.5 years (range 1–146 months). Permanent morbidity/mortality was 3.4%, including two deaths. Over a follow-up period of 364 patient-years, 1 stroke occurred (0.27% per year). At last follow-up, 41 previously disabled patients [CAD, 31/93 (33.3%); VAD, 10/23 (43.5%)] were no longer disabled; no patient reported worsened disability.ConclusionsPatients with CAD and VAD differ significantly in presentation, indications for treatment, and treatment methods. Endovascular treatment of CAD and VAD has low procedural morbidity and is associated with a low incidence of future stroke.

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Bilateral Carotid and Vertebral Artery Dissection from Blunt Trauma

Case Reports in Emergency Medicine ◽

10.1155/2018/1919034 ◽

2018 ◽

Vol 2018 ◽

pp. 1-3

Author(s):

Catherine Coss ◽

Jeffrey Jones

Keyword(s):

Emergency Department ◽

Vertebral Artery ◽

Blunt Trauma ◽

Intracranial Hemorrhage ◽

Motor Vehicle ◽

Vertebral Artery Dissection ◽

Diagnosis And Treatment ◽

Artery Dissection ◽

Vehicle Collision ◽

Bilateral Carotid

Carotid and vertebral artery injuries are rare following blunt trauma. They can, however, lead to severe consequences with a significant associated rate of stroke and intracranial hemorrhage, particularly if the diagnosis and treatment are delayed. We report a case of a 23-year-old female who presented to the Emergency Department with bilateral carotid and vertebral artery dissection following a motor vehicle collision (MVC).

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