Case report
Stroke after chiropractic manipulation as a result of extracranial postero-inferior cerebellar artery dissection*

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Abstract

Objective: To describe a case of dissection of the postero-inferior cerebellar artery (PICA) after cervical manipulation. Clinical Features: After cervical manipulation, a 42-year-old woman had a cerebellar syndrome related to an infarct in the area supplied by the PICA, confirmed by computed tomography of the brain. Cerebral angiography showed a normal appearance of the vertebral artery, a cervical extradural origin of PICA, and a dissection of the latter at the C1-C2 level. Intervention and Outcome: Anticoagulant treatment with heparin was implemented. A positive outcome was achieved after 3 weeks. Conclusion: Anatomical variations of the vertebral arteries and their branches are not infrequent and may constitute a predisposing factor to complications after neck manipulation. (J Manipulative Physiol Ther 2002;25:588-90)

Introduction

Vertebro-basilarstroke after cervical spine manipulation is well known and is generally the result of vertebral artery dissection at the C1-C2 level.

The postero-inferior cerebellar artery (PICA) is a cerebellar artery that generally originates from the vertebral artery at the intradural level and is not usually injured after a cervical trauma. However, this artery may sometimes originate from the vertebral artery below the level of the foramen magnum. In this case, the first few centimeters are situated at the cervical level and have close anatomic links with the first cervical vertebrae. Consequently, the PICA can be injured directly after cervical trauma if its origin is extracranial. We describe a case of PICA dissection after cervical manipulation.

Section snippets

Case report

A 42-yr-old woman had chronic neckaches that responded poorly to anti-inflammatory and antalgic treatments. Clinical examination by a chiropractor revealed stiffness of the neck with muscular contraction. In addition to spontaneous pains in the neck, the manipulation during the clinical exam provoked a radiation of the pain toward her arm and the external forearm on the right side. Neurologic examination was normal. A magnetic resonance imaging (MRI) scan of the cervical spine carried out 1

Discussion

Manipulation of the cervical spine is used in the treatment of neck pain and muscle-tension headache. Such therapy may expose patients to vertebrobasilar ischemia and lesions of the brain stem. Such serious accidents with serious consequences and sometimes permanent invalidity have been estimated at about 200 in the literature1, 2; they are usually secondary to dissection of the vertebral artery.3, 4, 5, 6, 7, 8, 9, 10, 11, 12

Specific clinical syndromes, such as the locked-in and Wallenberg

Conclusion

Dissection of cervical arteries does not only include the vertebral and carotid arteries. Dissection of the PICA, after neck manipulation, is possible if its origin is extracranial. We emphasise that these anatomic variations may constitute a predisposing factor for stroke after spinal manipulative therapy of the neck.

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