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

2011 ◽  
Vol 115 (6) ◽  
pp. 1197-1205 ◽  
Author(s):  
Felipe C. Albuquerque ◽  
Yin C. Hu ◽  
Shervin R. Dashti ◽  
Adib A. Abla ◽  
Justin C. Clark ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Vertebral Artery ◽  
Basilar Artery ◽  
Arterial Injury ◽  
Neurological Deficits ◽  
Endovascular Stenting ◽  
Chiropractic Manipulation ◽  
Patient Series ◽  
Patterns Of Injury

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.

A fatal, chronically growing basilar artery: a new type of dissecting aneurysm

1996 ◽  
Vol 84 (6) ◽  
pp. 962-971 ◽  
Author(s):  
Tohru Mizutani
Keyword(s):  
Mr Imaging ◽  
Basilar Artery ◽  
Dissecting Aneurysm ◽  
Neurological Deficits ◽  
Vertebrobasilar Insufficiency ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Basilar Arteries ◽  
Fine Print

✓ A long-term follow-up study (minimum duration 2 years) was made of 13 patients with tortuous dilated basilar arteries. Of these, five patients had symptoms related to the presence of such arteries. Symptoms present at a very early stage included vertebrobasilar insufficiency in two patients, brainstem infarction in two patients, and left hemifacial spasm in one patient. Initial magnetic resonance (MR) imaging in serial slices of basilar arteries obtained from the five symptomatic patients showed an intimal flap or a subadventitial hematoma, both of which are characteristic of a dissecting aneurysm. In contrast, the basilar arteries in the eight asymptomatic patients did not show particular findings and they remained clinically and radiologically silent during the follow-up period. All of the lesions in the five symptomatic patients gradually grew to fantastic sizes, with progressive deterioration of the related clinical symptoms. Dilation of the basilar artery was consistent with hemorrhage into the “pseudolumen” within the laminated thrombus, which was confirmed by MR imaging studies. Of the five symptomatic patients studied, two died of fatal subarachnoid hemorrhage (SAH) and two of brainstem compression; the fifth patient remains alive without neurological deficits. In the three patients who underwent autopsy, a definite macroscopic double lumen was observed in both the proximal and distal ends of the aneurysms within the layer of the thickening intima. Microscopically, multiple mural dissections, fragmentation of internal elastic lamina (IEL), and degeneration of media were diffusely observed in the remarkably extended wall of the aneurysms. The substantial mechanism of pathogenesis and enlargement in the symptomatic, highly tortuous dilated artery might initially be macroscopic dissection within a thickening intima and subsequent repetitive hemorrhaging within a laminated thrombus in the pseudolumen combined with microscopic multiple mural dissections on the basis of a weakened IEL. The authors note and caution that symptomatic, tortuous dilated basilar arteries cannot be overlooked because they include a group of malignant arteries that may grow rapidly, resulting in a fatal course.

Treatment of Dissecting Distal Vertebral Artery (V4) Aneurysms With Flow Diverters

2017 ◽  
Vol 15 (1) ◽  
pp. 1-9 ◽  
Author(s):  
Jacquelyn A Corley ◽  
Ali Zomorodi ◽  
L Fernando Gonzalez
Keyword(s):  
Vertebral Artery ◽  
Neurological Deficits ◽  
Medication Regimen ◽  
Antiplatelet Medication ◽  
Average Improvement ◽  
Multiple Challenges ◽  
Partial Thrombosis ◽  
Flow Diverters ◽  
Dissecting Aneurysms

Abstract BACKGROUND Dissecting aneurysms of the intracranial vertebral arteries are rare; however, treatment of these presents multiple challenges, including high risk of rebleeding, development of thromboembolic strokes, and progressive partial thrombosis. Flow diverters, such as Pipeline Endovascular Devices (PEDs; Covidien, Medtronic Inc, Dublin, Ireland), have emerged as a potential treatment option. OBJECTIVE To present our experience with patients treated at our institution with PEDs for dissecting distal vertebral artery (V4 segment) aneurysms. METHODS A retrospective search of our prospectively maintained database was performed between January 2014 and December 2016. We queried our database for all patients treated with PED for dissecting aneurysms of the V4 segment. Information was gathered including demographics, the location and morphology of the aneurysm, the clinical presentation, specific form of treatment, complications, antiplatelet medication regimen, and follow-up time. RESULTS There were a total of 9 patients with dissecting V4 aneurysms treated with PED during the study period. All were treated initially with an average of 1.2 PEDs. All patients were followed with at least one repeat diagnostic angiogram and there was no residual aneurysm seen in 8 of 9 cases. In those that presented with neurological deficits, there was an average improvement in modified Rankin Scale of 2.85 points. CONCLUSION PED is a safe and effective tool that can be used to treat ruptured dissecting aneurysms of this specific segment of the posterior circulation, but it does require close management of antiplatelet therapy in the setting of subarachnoid hemorrhage and close angiographic follow-up.

Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries

1993 ◽  
Vol 78 (2) ◽  
pp. 192-198 ◽  
Author(s):  
Randall T. Higashida ◽  
Fong Y. Tsai ◽  
Van V. Halbach ◽  
Christopher F. Dowd ◽  
Tony Smith ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Basilar Artery ◽  
Cerebral Circulation ◽  
Transluminal Angioplasty ◽  
Content Type ◽  
Atherosclerotic Stenosis ◽  
Basilar Arteries ◽  
Posterior Cerebral Circulation ◽  
Fine Print

✓ Transluminal angioplasty for hemodynamically significant stenosis (> 70%) involving the posterior cerebral circulation is now being performed by the authors in selected cases. A total of 42 lesions affecting the vertebral or basilar artery have been successfully treated by percutaneous transluminal angioplasty techniques in 41 patients. The lesions involved the proximal vertebral artery in 34 cases, the distal vertebral artery in five, and the basilar artery in three. Patients were examined clinically at 1 to 3 and 6 to 12 months after angioplasty. Three (7.1%) permanent complications occurred, consisting of stroke in two cases and vessel rupture in one. There were four (9.5%) transient complications (< 30 minutes): two cases of vessel spasm and two of cerebral ischemia. Clinical follow-up examination demonstrated improvement of symptoms in 39 cases (92.9%). Radiographic follow-up studies demonstrated three cases (7.1 %) of restenosis involving the proximal vertebral artery; two were treated by repeat angioplasty without complication, and the third is being followed clinically while the patient remains asymptomatic. In patients with significant atherosclerotic stenosis involving the vertebral or basilar artery territories, transluminal angioplasty may be of significant benefit in alleviating symptoms and improving blood flow to the posterior cerebral circulation.

scholarly journals Dissection of Bilateral Intracranial Vertebral Artery with Basilar Artery Involvement: A Case Report of a Patient Free from Neurological Deficits

2007 ◽  
Vol 46 (17) ◽  
pp. 1467-1470 ◽  
Author(s):  
Noriko Hagiwara ◽  
Masahiro Kamouchi ◽  
Tooru Inoue ◽  
Setsuro Ibayashi ◽  
Mitsuo Iida ◽  
...  
Keyword(s):  
Case Report ◽  
Vertebral Artery ◽  
Basilar Artery ◽  
Neurological Deficits

scholarly journals Osteoid Osteoma and Osteoblastoma of the Cervical Spine: The Cause of Unusual Persistent Neck Pain

2010 ◽  
Vol 6;13 (6;12) ◽  
pp. 549-554
Author(s):  
Tuncay Kaner
Keyword(s):  
Cervical Spine ◽  
Retrospective Study ◽  
Neck Pain ◽  
Osteoid Osteoma ◽  
Tumor Resection ◽  
Spinal Instrumentation ◽  
The Other ◽  
Neurological Deficits ◽  
Common Symptom

Background: The most important symptom in patients with osteoid osteoma and osteoblastoma is a resistant localized neck pain and stiffness in the spine. Objective: To evaluate and analyze 6 cases of osteoid osteoma and osteoblastoma of the cervical spine that were surgically treated over a 7-year period and to emphasize the unusual persistent neck pain associated with osteoid osteoma and osteoblastoma of the cervical spine. Study Design: Retrospective study. Methods: Six patients, 3 male and 3 female, with a mean age of 21 years (range 16-31) diagnosed with osteoid osteoma or osteoblastoma during 2003 to 2009 were analyzed retrospectively. The preoperative neurological and clinical symptoms, neck pain duration, preoperative deformity, location of lesion, radiological findings, surgical technique and clinical follow-up outcomes of each patient were evaluated. Results: The average follow-up duration was 40.5 months (range, 19 to 83 months). Three patients had osteoid osteoma (2 female and one male), and 3 patients had osteoblastoma (one female and 2 male). Two male patients had recurrent osteoblastoma. The locations of the lesions were as follows: C7 (2 patients), C3 (one patient), C2 (one patient), C3-C4 (one patient) and C5-C6 (one patient). The most common symptom was local neck pain in the region of the tumor. Among all patients, only one patient, who had osteoblastoma, had neurological deficits (right C5-C6 root symptoms). The other patients had no neurological deficits. All patients were treated with surgical resection using microsurgery. Two patients underwent only tumor resection, one patient underwent tumor resection and fusion, and the other 3 patients underwent tumor resection, fusion and spinal instrumentation. No perioperative complications developed in any of our patients. There was no tumor recurrence during the follow-up period. Limitations: A retrospective study with 6 analyses of cases. Conclusion: Surgical treatment of osteoid osteoma and osteoblastoma of the spine has been standardized. The most common symptom of osteoid osteoma and osteoblastoma of the cervical spine is local persistent neck pain in the region of the tumor. This symptom can be significant in the diagnosis of these tumors. Key words: neck pain, osteoid osteoma, osteoblastoma, bone tumors, cervical spine

scholarly journals Spontaneous Vertebral Artery Dissection Presenting with Crescendo TIAs and Headache

2019 ◽  
pp. 1-6
Author(s):  
Dr. Nosakhare I Idehen ◽  
Dr. Mohammed Awad
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Vertebral Artery Dissection ◽  
Symptomatic Improvement ◽  
Neurological Deficits ◽  
Artery Dissection ◽  
Neurological Sequelae ◽  
Cerebellar Artery ◽  
Ct Brain

We present the case of a man in his thirties who had attended the emergency department with complaint of a distressing headache and associated intermittent facial droop with occasional slurred speech. The patient’s symptoms were bizarre in their nature as they were random, not sustained and he had long intervals when he was asymptomatic and was his normal self. During the course of admission his symptoms evolved resulting in neurological deficits which were more sustained, prompting the need for further imaging beyond the initial plain CT brain which showed no abnormality. This led to the diagnosis of vertebral artery dissection (VAD) complicated with an ischaemic stroke in the posterior inferior cerebellar artery distribution (PICA) on MRI/MRA. Dual anti-platelet treatment was commenced with the patient attaining gradual symptomatic improvement prior to discharge. He has reported some degree of neurological sequelae which he described as intermittent poor coordination on follow up visit in clinic after discharge.

scholarly journals Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 856-866 ◽  
Author(s):  
Martin H. Pham ◽  
Rudy J. Rahme ◽  
Omar Arnaout ◽  
Michael C. Hurley ◽  
Richard A. Bernstein ◽  
...  
Keyword(s):  
Systematic Review ◽  
Vertebral Artery ◽  
Success Rate ◽  
Artery Dissection ◽  
Endovascular Management ◽  
Review Of The Literature ◽  
Technical Success ◽  
Endovascular Stenting ◽  
Technical Success Rate

Abstract BACKGROUND: Carotid and vertebral artery dissections are a leading cause of stroke in young individuals. OBJECTIVE: To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection. METHODS: We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections. RESULTS: For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months). CONCLUSION: Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Cervical spine injury from gunshot wounds

2014 ◽  
Vol 21 (3) ◽  
pp. 442-449 ◽  
Author(s):  
Narlin Beaty ◽  
Justin Slavin ◽  
Cara Diaz ◽  
Kyle Zeleznick ◽  
David Ibrahimi ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Neurological Deficit ◽  
Neurological Outcome ◽  
Treatment Algorithm ◽  
Gunshot Wounds ◽  
Neurological Deterioration ◽  
Neurological Deficits ◽  
Cervical Instability ◽  
Cord Injury

Object Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. Methods A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. Results Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients underwent decompression alone for neurological deterioration and persistent compressive injury, both of whom experienced marked neurological recovery. Follow-up was obtained in 92% of cases. Three patients undergoing stabilization converted at least 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and the remaining operative cases experienced small ASIA motor score improvement. Eighteen patients underwent inpatient MRI. No patient suffered complications or neurological deterioration related to retained metal. Three of 28 patients presenting with AIS Grade A improved to Grade B. For those 12 patients with incomplete injury, 1 improved from AIS Grade C to D, and 3 improved from Grade D to E. Conclusions Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.

scholarly journals Basilar artery fenestration associated with aneurysms treated by endovascular approach

2012 ◽  
Vol 19 (4) ◽  
pp. 273-279
Author(s):  
Stefanita Dima ◽  
Mugurel Radoi
Keyword(s):  
Endovascular Treatment ◽  
Basilar Artery ◽  
Surgical Techniques ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Digital Subtraction ◽  
Vertebral Arteries ◽  
Endovascular Approach ◽  
Embolization Procedure

Abstract Introduction: Arterial fenestrations are associated with saccular aneurysms that are often difficult to treat with open surgical techniques. Basilar artery fenestration reported in the literature is highly variable depending on the technique used. Typically fenestration occurs at the lower end of the basilar artery just at the vertebral arteries join. For basilar artery fenestrations associated with aneurysms endovascular embolization could be the first treatment choice. Methods: This study presented three cases of patients having basilar artery fenestration associated with aneurysm that were treated endovascularly. All patients underwent endovascular embolization by femoral approach, under general anesthesia. Results: In all three cases, no new neurological deficits were reported. Balloon remodeling technique was necessary in one patient that presented kissing aneurysms. The length of the follow-up was 3 years for 2 patients, and 1 year for one patient. All the aneurysms, except one, presented a small recanalization at four vessels digital subtraction angiography (DSA) control, but it remained stable even at the three years control. Conclusions: Endovascular treatment of basilar artery aneurysms associated with fenestrations is a safe and durable option. No second embolization procedure was necessary in our cases. No limb of the fenestration was necessary to be sacrificed. Larger series of patients treated with this method are needed to support our evidence.

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