Introduction

We report a rare case of a 33-year-old Caucasian male osteopath who developed extracranial vertebral artery dissection post self-manipulation of his cervical spine to treat his neck pain. The patient presented with a history of tingling and numbness in his right upper chest, right arm and forearm along with blurred vision in his right eye and unsteadiness.

Computed Tomography (CT) of head showed no evidence of acute infarction however a dense right vertebral artery was noted that raised the possibility of vertebral artery thrombosis/dissection. CT angiogram of the aortic arch and both carotids confirmed extracranial right vertebral artery dissection. He underwent magnetic resonance imaging (MRI) of his brain that showed infarcts in the posterior circulation including right cerebellum and medulla oblongata. He was treated with antiplatelet therapy.

Case report

A 33-year-old Caucasian male, an Osteopath by profession, presented to Accident and Emergency department with tingling and numbness of his right upper chest, right arm and forearm. He also complained of unsteadiness and blurred vision in his right eye. Symptoms started a few hours after self-manipulation of his cervical spine that he performed to treat his neck pain, which was going on for few weeks. Patient also reported transient dysphagia and speech impairment, both of which resolved by the time of his presentation to the hospital.

Physical examination showed right gaze nystagmus. Pupils were equal and reacting to light and accommodation, with no size difference. He had right sided cerebellar signs with impaired coordination and unsteadiness. CT of brain did not show acute infarction, but a dense right vertebral artery was noted on the CT scan of brain that raised the possibility of vertebral artery thrombosis/dissection.

Extra-cranial right vertebral artery dissection was confirmed on CT angiogram of aortic arch and both carotid arteries. He underwent MRI of his brain showed infarcts in the posterior circulation including right cerebellum and medulla oblongata. 

 

 Axial diffusion-weighted magnetic resonance imaging showing increased signal due to restricted diffusion in the right cerebellar hemisphere and medulla oblongata, suggestive of acute infarctions.

 

Fig 1 Axial diffusion-weighted magnetic resonance imaging showing increased signal due to restricted diffusion in the right cerebellar hemisphere and medulla oblongata, suggestive of acute infarctions.

 

Coronal magnetic resonance T1-weighted image shows high T1 signal in the right vertebral artery wall due to mural haematoma

 

Fig 2 Coronal magnetic resonance T1-weighted image shows high T1 signal in the right vertebral artery wall due to mural haematoma.

 

Fig 3 Axial computed tomography angiogram at the level of C1 vertebra showing poor opacification of the right vertebral artery and narrow eccentric enhancement of the lumen.

Fig 3 Axial computed tomography angiogram at the level of C1 vertebra showing poor opacification of the right vertebral artery and narrow eccentric enhancement of the lumen.

 

His blood test results were normal showed  Haemoglobin 150g/L, White Cell Count 9.87 10 9/L , Platelet 191 10 9/L, Haematocrit 0.418, MCV 83.6fl  , RCC 5 10 9/L , MCH 30pg Sedimentation Rate 2mm/hour, Sodium 132mmol/L, Potassium 4.3mmol/L, Urea 5mmol/L, Creatinine 76umol/L, Cholesterol 5mmol/L, Plasma Glucose 6.2mmol/L, HbA1c (IFCC Standard) 35mmol/mol, eGFR (CKD-EPI) > 90ml/min/1.73m2. Serum Triglycerides 1mmol/L, Calculated Non-HDL Cholesterol 3.6 mmol/L (0 - 2.5mmol/L), Serum HDL Chol 1.4mmol/L, Calculated LDL Cholesterol 3.1mmol/L, Serum Cholesterol/HDL ratio 3.6.

Plasma homocysteine 11.3umol/L, Beta 2 microglobulin 1.28mg/L, Lupus Anticoagulant Screen Negative. IgG Cardiolipin 2.20 g/L, IgM Cardiolipin 1.60g/L, Antinuclear antibodies Negative, Anti DNA Antibodies 1.0 IU/ml, International Normalised Ratio 1.0, Prothrombin Time 11.3s, APT Ratio 0.92.

Thrombolytic therapy was not administered owing to his late presentation. Antiplatelet therapy with aspirin and clopidogrel was administered. He was discharged home with complete recovery after a spell of rehabilitation.

Discussion

An overall incidence of vertebral artery dissection of approximately 1-1.5 per 100,000 has been reported in a previous study.1 Spontaneous dissections of the carotid and vertebral artery account for only about 2% of all ischemic strokes.2

The phenomenon of dissection refers to tear in the internal lining of the artery leading to extravasation of blood to external layers leading to clot formation, with neurologic sequelae from occlusion or embolisation. Posterior neck pain can be a main presenting symptom of dissection of vertebral artery.3

Vertebral dissection can occur as a result of physical trauma to the neck including chiropractic and osteopathic manipulation of neck. An Australian Cricketer, Philip Hughes, aged 25, died two days after being struck on the top of the neck by a ball during a domestic match leading to the vertebral artery dissection prompting significant bleeding to the brain.

Ehler Danlos Syndrome and other connective tissue disorders are known to cause stroke in young patients and account for 1-4% of the cases of spontaneous dissection of vertebral artery.

An analysis of data in 2006 on population-based sample from 1987 to 20034 found that the incidence of vertebral artery dissection is twice less common than the internal carotid artery dissection. CT angiogram of brain has become a gold standard in the diagnosis of arterial dissection and is available out of hours.

MRI of brain is equally effective, less invasive but is usually not available out of hours. Following the first episode of dissection of vertebral artery, 2% of patients may experience a subsequent episode within the first month after that annual risk of recurrence is 1%. Recurrence is common in younger patients, and in those with a family history of cervical artery dissection or with a diagnosis of Ehlers-Danlos syndrome and fibromuscular dysplasia.5

There is limited long-term outcome data available  after vertebral artery dissection.6 however 70-85% patients  with extracranial vertebral dissection achieve complete recovery, 10-25% are left with major disabling neurological deficits and death occurs rarely  in  only 5-10% of the cases.7

Learning Points

  • Osteopathic cervical neck manipulation can lead to vertebral artery dissection
  • Following the first episode of dissection of vertebral artery, 2% of patients may experience a subsequent episode within the first month after that annual risk of recurrence is 1%
  • Recurrence is common in younger patients, in those with a family history of dissection and with a diagnosis of Ehlers-Danlos syndrome and fibromuscular dysplasia

 


Dr Mansoor Zafar, Specialty Registrar. Department of Gastroenterology, Conquest Hospital, East Sussex Healthcare Trust

Dr Chemindra Biyanwila, Consultant Stroke Physician. Department of Stroke Medicine, Eastbourne District General Hospital

Dr Maria Filyridou, Consultant Radiologist. Department of Radiology, Eastbourne District General Hospital

Dr. MJH Rahmani, Consultant Physician. Department of Health and Ageing, Conquest Hospital, East Sussex Healthcare Trust

m.rahmani3@nhs.net


 

References

  1. Bogousslavsky, Julien, and F. Regli. “Ischemic Stroke in Adults Younger Than 30 Years of Age.” Archives of Neurology, vol. 44, no. 5, May 1987, p. 479
  2. Bassetti, C., et al. “Recurrence of Cervical Artery Dissection. A Prospective Study of 81 Patients.” Stroke, vol. 27, no. 10, Oct. 1996, pp. 1804–07
  3. Lucas, Christian, et al. “Stroke Patterns of Internal Carotid Artery Dissection in 40 Patients.” Stroke, vol. 29, no. 12, Dec. 1998, pp. 2646–48
  4. Lee, V. H., et al. “Incidence and Outcome of Cervical Artery Dissection: A Population-Based Study.” Neurology, vol. 67, no. 10, Nov. 2006, pp. 1809–12
  5. Debette, Stéphanie, and Didier Leys. “Cervical-Artery Dissections: Predisposing Factors, Diagnosis, and Outcome.” The Lancet Neurology, vol. 8, no. 7, July 2009, pp. 668–78
  6. Arauz, Antonio, et al. “Dissection of Cervical Arteries: Long-Term Follow-Up Study of 130 Consecutive Cases.” Cerebrovascular Diseases, vol. 22, no. 2–3, Karger Publishers, 2006, pp. 150–54
  7. Arnold, Marcel, et al. “Vertebral Artery Dissection: Presenting Findings and Predictors of Outcome.” Stroke, vol. 37, no. 10, Oct. 2006, pp. 2499–503