Introduction/Purpose Vertebral artery dissection is a recognized cause of ischemic stroke in young and middle‐aged adults, often presenting with headache, neck pain, and focal neurologic deficits. Minor trauma, including neck manipulation, is a statistically significant risk factor for cervical artery dissection, with several case‐control and cohort studies demonstrating an association, particularly in younger patients. The vertebral arteries ascend through the transverse foramina of the cervical vertebrae, making them susceptible to mechanical stress from abnormal spinal curvature. Cervical scoliosis alters the bony alignment and curvature, causing the vertebral artery pathway to be elongated, kinked, or compressed, especially at the apex of the spinal curve. We suspect in patients with abnormal cervical biomechanisms the vertebral arteries are more vulnerable to injury during high velocity cervical manipulation. This case aims to highlight the risk of arterial dissection in a patient with scoliosis after undergoing neck manipulation. Materials/Methods A 37‐year‐old right‐handed male with a history of migraine headaches presented with acute onset diplopia and vertigo accompanied by nausea, vomiting, and right facial sensory loss on awakening. The patient reported recent chiropractic cervical manipulation days prior to symptom onset. Neurological examination revealed right‐sided facial sensory deficits, multidirectional nystagmus, and right homonymous hemianopia. CT angiography demonstrated right vertebral artery dissection in V2 and V3 and subtle luminal changes over the left V2 segment with scoliotic curve of the cervical spine and upper thoracic spine. MRI and MR angiography demonstrated multifocal acute infarcts in the posterior circulation and evidence of vertebral artery dissection. Additional workup included a lipid panel which showing an LDL of 137 mg/dL and a transthoracic echocardiogram revealing a bicuspid aortic valve. Results The patient was initiated on dual antiplatelet therapy with aspirin and clopidogrel for secondary prevention, consistent with American Heart Association guidance for extracranial cervical artery dissection, with plans to transition to single antiplatelet therapy after 3 months, assuming no recurrent events and stable follow up imaging. Ultimately, the patient had improvement in his visual symptoms including complete resolution of right homonymous hemianopia during his hospitalization. Given his elevated LDL, the patient was started on a high intensity statin therapy. Secondary prevention strategies included aggressive vascular risk factor modification, avoidance of further neck manipulation or trauma, and close outpatient follow‐up with repeat vascular imaging in 3 months. The patient was also referred to medical genetics to further evaluate possible underlying connective tissue disorders. He was counseled regarding the statistical association between cervical manipulative therapy and vertebral artery dissection, and the importance of prompt medical evaluation for any future neurological symptoms. Conclusions Cervical scoliosis is not a well‐established independent risk factor for vertebral artery dissection. However, when combined with cervical high velocity manipulations, the vertebral arteries are likely to be more vulnerable to injury and lead to dissections and strokes. Further research is warranted on this topic. Finally, early recognition and evidence‐based antithrombotic therapy are critical to optimizing outcomes in patients with arterial dissection.
Traylor et al. (Sat,) studied this question.