Neuroradiology

Traumatic Vertebral Artery Pseudoaneurysm Following Chiropractic Manipulation 1



Kendrick C. Davidson, M.D., Edward C. Weiford, M.D., and G. David Dixon, M.D. A vertebral artery pseudoaneurysm accompanied by serious neurological injury was seen in a 42-year-old woman who had undergone chiropractic manipulation of the neck. Such manipulation is a potential cause of neurological injury due to trauma to the cervical spine and the major vessels of the neck. The arterial pattern in this case was similar to that of angiodysplasia except for narrowing and irregularity of the vertebral artery. INDEX TERMS:

Chiropractic. Vertebral Arteries. wounds and injuries

Radiology 115:651-652, June 1975

• CRANIOCERVICAL vessel injuries caused by nonpenetrating trauma to the head and neck are the result of vehicular accidents and sports injuries (2,7, 10). Because of their relatively unprotected location in the soft tissues of the neck, the carotid arteries are more subject to trauma than the vertebral arteries, which are partially protected but relatively restricted by the deeper, discontinuous bony canals formed by the transverse processes of the cervical spine. Though more reports have stressed carotid than vertebral artery injuries, a significant number of vertebral artery injuries with varying degrees of vertebrobasilar neurological deficit (1, 5, 8, 10, 12) have been reported following vehicular, home, and sports injuries. In addition, injury to the vertebrobasilar artery following chiropractic manipulation of the spine has long been recognized as a potentially preventable cause of severe neurological damage (4, 9, 11). We wish to describe such a case in which angiographic evaluation and follow-up were performed.

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Fig. 1. Right brachial arteriogram (subtraction print) shows a pseudoaneurysm of the vertebral artery (large arrow), with irregular narrowing below it (small arrows).

CASE REPORT A 42-year-old woman was admitted to the hospital 11 hours after undergoing chiropractic manipulation of the neck; this was her fourth visit to the chiropractor in four weeks. During the most recent procedure, she had experienced several symptoms, all of rapid onset: dizziness, nausea, vertigo, diplopia, roaring in the right ear, and inability to stand when helped to her feet. The nausea and vertigo persisted throughout the day, and the patient also noticed a steady "squishing" noise in her right ear. Neurosurgical examination revealed a blood pressure of 126176, considerable right upper posterior cervical pain, paresis of the right fourth cranial nerve, complete right peripheral facial palsy, constant spontaneous severe rotatory nystagmus (especially on gazing to the left but to some degree on the right as well), and apparently complete neurosensory hearing loss in the right ear with some slight residual vestibular function as shown by ice-water caloric testing. The SMA-12, electrocardiograms, radiographs of the chest, cervical spine, and skull, and tomograms of the petrous bone were normal during the 13 days that the patient was hospitalized. Spinal puncture on the second hospital day showed opening and closing pressures of 140 and 110 mm of water, respectively, 4 white blood cells and 157 red blood

cells per high-power field, and normal cerebrospinal fluid on electrophoresi_s. Right brachial arteriography via a retrograde injection on the third hospital day demonstrated a pseudoaneurysm of the right vertebral artery at C-2 (Fig. 1) with irregularity due to spasm or vascular or perivascular bleeding below it. No occlusion of any vertebrobasilar branch could be seen. The patient's vomiting and diplopia cleared in 1 % days. Nystagmus had largely cleared by the second day, but a small amount persisted to the thirteenth day. Slight right midfacial movement returned by the third day, and by the tenth day almost all vertigo was gone. Upon discharge on the thirteenth day, some high right residual neck pain, complete right conductive hearing loss, and moderate right facial paresis persisted. Re-examination 3 months later revealed "neurosensory hearing loss in right ear· sloping from 60 decibels at 25 Hz to 20 decibels at 2000 Hz, speech reception threshold of 30

1 From the Department of Radiology (K. C. D., G. D. D.) and Section of Neurosurgery (E. C. W.), St. Luke's Hospital, Kansas City, Mo. Accepted for publication in January 1975. sjh

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C. DAVIDSON AND OTHERS

June 1975

the carotid, vertebral, and basilar arteries and their branches. Recently, Miller and Burton (6) reviewed 12 neurological injuries related to chiropractic manipulation in the English literature. However, previous reports do not mention pseudoaneurysm of the vertebral artery in a patient who survived the neurological injury and subsequently underwent arteriography. More frequently, the etiology of post-traumatic vertebral artery pseudoaneurysm and arteriovenous fistula is localized sharp trauma from a gunshot or knife wound, fracture, metal or glass shard injury followng an automobile accident, intravascular arteriography, cervical disk surgery, etc. Fibrodysplasia of a vertebral artery, a very unusual occurrence recently discussed by Stanley et a/. (13), might be considered in the differential diagnosis as a cause of aneurysmal change and irregularity of the vertebral arteries similar to the appearance seen in our patient; however, resolution of the associated vertebral artery narrowing and irregularity due apparently to spasm and/or hemorrhage suggest a different diagnosis. Since our patient's condition improved and stabilized, it was not considered advisable to perform reconstructive surgery considering the relatively greater risks involved. However, this case illustrates the potentially serious neurological consequences of chiropractic manipulation of the neck and resulting blunt, closed trauma to the vertebral artery. Department of Radiology St. Luke's Hospital Kansas City, Mo. 64111

REFERENCES Fig. 2. Follow-up right vertebral arteriogram. Anteroposterior and right lateral views reveal a persistent right vertebral pseudoaneurysm.

decibels, and 72 % discrimination, definite recruitment averaging 20-25 decibels," residual right upper facial paresis (forehead and periorbital area), but no extremity weakness, vertigo, nystagmus, ataxia, or head or neck bruits. The patient's gait and balance were normal. Bilateral vertebral catheter arteriography (Fig. 2) revealed the persistent right upper vertebral artery pseudoaneurysm but no residual spasm. or other irregularity of the vessel. DISCUSSION Vertebral and basilar arterial trauma may be due to a variety of reasons, of which chiropractic manipulation of the neck has repeatedly been stressed as a potentially lethal but preventable cause. Possible mechanisms of injury to the upper vertebral artery at the atlanto-axial level are thought to include stretching, tearing, or occlusion of the relatively fixed (by the transverse processes) ipsilateral upper cervical vertebral artery during forced extension and/or contralateral rotation of the extended cervical spine (10, 15). Possible consequences include subintimal, vascular, or perivascular hemorrhage accompanied by narrowing, spasm, and thrombosis of or embolization from the vertebral artery resulting in immediate or delayed neurological injury. In some cases, underlying vertebrobasilar artery anomalies may further predispose to relative ischemia (3, 14). In recent years, increasingly thorough neuroradiological investigation of vascular trauma has led to more detailed recognition of many types of injuries of

1. Carpenter S: Injury of neck as cause of vertebral artery thrombosis. J Neurosurg 18:849-853, Nov 1961 2. Gurdjian ES, Hardy WG, Lindner OW, et al: Closed cervical cranial trauma associated with involvement of carotid and vertebral arteries. J Neurosurg 20:418-427, May 1963 3. Hutchinson EC, Yates PO: The cervical portion of the vertebral artery. A clinico-pathological study. Brain 79:319-331, Jun

1956 4. Kanshepolsky J, Danielson H, Flynn RE: Vertebral artery insufficiency and cerebellar infarct due to manipulation of the neck. Report of a case. Bull LA Neurol Soc 37:62-65, Apr 1972 5. Marks RL, Freed MM: Nonpenetrating injuries of the neck and cerebrovascular accident. Arch Neurol 28:412-414, Jun 1973 6. Miller RG, Burton R: Stroke following chiropractic manipulation of the spine. JAMA 229: 189-190, 8 Jul 1974 7. Monson DO, Saletta JD, Freeark RJ: Carotid vertebral trauma. J Trauma 9:987-999, Dec 1969 8. Nagler W: Vertebral artery obstruction by hyperextension of the neck: report of three cases. Arch Phys Med Rehabil 54:237240, May' 1973 9. Pratt-Thomas HR, Berger KE: Cerebellar and spinal injuries after chiropractic manipulation. JAMA 133:600-603, 1 Mar 1947 10. Schneider RC, Gosch HH, Taren JA, et al: Blood vessel trauma following head and neck injuries. Clin Neurosurg 19:312-

354, 1972 11. Schwarz GA, Geiger JK, Spano AV:

Posterior inferior cerebellar artery syndrome of Wallenberg after chiropractic manipulation. Arch Intern Med 97:352-354, Sep 1956 12. Shaw C-M, Alvord EC Jr: Injury of the basilar artery associated with closed head trauma. J Neurol Neurosurg Psychiatry 35: 247-257, Apr 1972 13. Stanley Je, Fry WJ, Seeger JF, et al: Extracranial internal carotid and vertebral artery fibrodysplasia. Arch Surg 109:215-222, Aug 1974 14. Stopford JSB: The arteries of the pons and medulla oblongata. Part II. J Anat 50:131-164,1915-1916 15. Tatlow WFT, Bammer HG: Syndrome of vertebral artery compression. Neurology' 7:331-340, May 1957

Traumatic vertebral artery pseudoaneurysm following chiropractic manipulation.

A vertebral artery pseudoaneurysm accompanied by serious neurological injury was seen in a 42-year-old woman who had undergone chiropractic manipulati...
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