title: Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management.
abstract: OBJECTIVE
  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 V(4) 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.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA. neuropub@chw.edu
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Yin C
authors.initials: YC
authors.lastname: Hu
authors.forename: Shervin R
authors.initials: SR
authors.lastname: Dashti
authors.forename: Adib A
authors.initials: AA
authors.lastname: Abla
authors.forename: Justin C
authors.initials: JC
authors.lastname: Clark
authors.forename: Brian
authors.initials: B
authors.lastname: Alkire
authors.forename: Nicholas
authors.initials: N
authors.lastname: Theodore
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
mesh_terms: D000328:Adult; D000368:Aged; D001488:Basilar Artery / Q000293:injuries* / Q000473:pathology; D003399:Craniotomy; D016208:Databases, Factual; D017809:Fatal Outcome; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D026882:Manipulation, Chiropractic / Q000009:adverse effects*; D008875:Middle Aged; D015607:Stents; D014711:Vertebral Artery / Q000293:injuries* / Q000473:pathology; D020217:Vertebral Artery Dissection / Q000209:etiology* / Q000601:surgery / Q000628:therapy; D014715:Vertebrobasilar Insufficiency / Q000209:etiology* / Q000601:surgery / Q000628:therapy