A 29 y.o. male presents with dizziness after a chiropractor manipulates his neck.
Outside CT is normal.
What do you notice on the CTA of a patient with a similar problem?
Hint: our patient had a homonymous hemianopsia
Our patient had a dissection of the vertebral artery after a chiropractic manipulation and suffered a stroke. While this has been reported in the literature many times, it is a rare event in the general population. It is however it accounts for 10-25% of strokes in patients younger than 45. One in 48 chiropractors report having experienced such an event in their practice.
It is estimated that 1 in 20,000 cervical spine manipulations cause a stroke, but the most common cause of dissection is blunt trauma. Patients with connective tissue disoders like Ehlers Danlos are more likely to suffer a vertebral dissection. The dissection may lead to a delayed stroke often days after the event.
the majority of dissections occur in segment 3
The majority of spontaneous dissections occur in segment 3 which can extend to segment 4. The dissection can by extracranial or intracranial with the extracranial dissections near C1,2. Extracranial dissections often present with a bruit. Intracranial dissections are associated with subarachnoid hemorrhage 50% of the time and associated with a worse prognosis.
vertebral dissections can lead to strokes as shown on this MRI of a young women with a fatal brainstem infarct after a chiropactor’s manipulation
Younger people often present with HA or neck pain. In older people lateral medullary strokes(Wallenberyg syndrome where there are pain and temperature changes on the opposite side of the dissection) and cerebellar infarcts occur with ataxia and nystagmus. Tongue deviation to the side of the lesion can occur. 10% of patients died from a vertebral dissection because of intracranial extension and brainstem infarct.
Our patient was treated with ASA and recovered.
A QUESTION TO PONDER
Does a HINTS exam ever case a vertebral dissection? The HINTS exam( head impulse, nystagmus, test of skew) was designed to determine whether someone is presenting with a posterior circulation stroke or just benign acute vestibular syndrome. It contains three parts: the first involves head impulse: rapidly jerking the head to the side while the pt fixes gaze on the examiners nose. As recommended , the jerking movement has to be forceful to be useful. There is no proof this could cause vertebral dissection but since vertebral dissection has been reported with minimal or no trauma, the jury is still out.
The head impluse test NORMAL IS BAD
Jones, J, Jones C, Nugent K. vertebral artery dissection after a chiropractor neck manipulation. 2-015 Proc Bayl Univ Med Cent Jan 28(1) :88-90.
Turner R, Lucke-Wold B, Boo S. et al. The potential dangers of neck manipulation & rish for dissection and devastating stroke: An illustrative case & review of the literature. Biomed Res Rev. 2018;2(1)
Hu Y,Du J, Liu Z, eet al. Vertebral artery dissection caused by atlantoaxial dislocation: a case report and review of literature. Childs Nerv syst. 2019 Jan:35(1):187-90.
Kattah, J, Talkad A, Wang D, Hsieh Y , Newman-Toker D. HINTS to diagnose stroke in the acute vestibular syndrome three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.2009 Stroke 40(11):3504-3510.