Keywords
vertebral artery dissection - cervical manipulation - stroke
Palavras-chave
dissecção das artérias vertebrais - manipulação cervical - isquemia cerebral
Introduction
Vertebral artery dissection (VAD) is a rare and sometimes unrecognized cause of stroke in patients younger than 45 years.[1]
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[3] Patients typically present with severe occipital headache and posterior nuchal pain following a recent head or neck injury; they also present a subsequent development of focal neurologic signs due to the ischemic lesion of the brainstem or cerebellum.[4]
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The overall incidence of VAD is of ∼ 1–1.5 per 100,000. Spontaneous VAD accounts for less than 1% of all ischemic strokes, but it is an important cause of ischemic stroke in young and middle-aged patients, accounting for ∼ 10% of such cases.[8]
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Herein, we describe a very rare case of bilateral vertebral artery dissection after a session of cervical therapy manipulation (chiropractic).
Case
A 32-year-old female patient presented at the Emergency Care Unit with severe headache, nauseas and vomiting, and somnolence. At neurological examination she had bilateral abducens nerve palsy and a Glasgow coma score of 9 points. Computed tomography (CT) images showed extensive right cerebellar ischemia with fourth ventricle and brainstem compression and supratentorial ventricular enlargement. Her family reported a medical visit three days after these events for a cervical pain that was extremely manipulated by this professional with strong lateral torsion.
Posterior cranial fossa decompression with external ventricular drain (EVD) was performed, and a four-intracranial vessel angiography was made. The initial angiography ([Figs. 1] and [2]) showed bilateral vertebral artery occlusion in the intracranial portion at proximal cervical segments. Also, a good collateral circulation through the extracranial carotid artery branches and a posterior communicating artery was observed, providing good blood flow for most of the brainstem and cerebellum. So, a double antiplatelet therapy with acetylsalicylic acid and clopidogrel was initiated.
Fig. 1 (A) Initial angiography showing right vertebral artery dissection (yellow arrow). (B) Angiography reconstruction showing right vertebral artery dissection (yellow arrow).
Fig. 2 (A) Initial angiography showing left vertebral artery dissection (yellow arrow). (B) Angiography reconstruction showing left vertebral artery dissection (yellow arrow). The white arrow shows the collateral circulation through the external carotid artery branches supplying irrigation for the left vertebral artery region.
The patient had a good recovery of her neurological condition after the procedure, but the nystagmus and the dizziness remained. After three days, the EVD was removed, and CT images showed completely decompression of the fourth-ventricle. After six days, the patient was discharged for physical and neurological rehabilitation.
After 30 days, a new angiography was performed ([Fig. 3]), showing the right vertebral artery completely recovered and the left vertebral artery still without flow. At this moment, she was asymptomatic. After 90 days, the antiplatelet therapy was stopped, and she remained asymptomatic.
Fig. 3 Angiography reconstruction made 30 days after the first endovascular exam. (A and B) The yellow arrows show the left vertebral artery flow recovery. (C) The white arrow points to the right vertebral artery that remains without flow. (D) The orange arrow shows the collateral branches from the external carotid artery to the right vertebral artery region.
Discussion
Arterial dissection is a vascular injury characterized by a tear in the artery wall with the development of intramural hematoma. Consequently, a lumen stenosis or an aneurysmal dilatation of the artery may occur. In the past, it was thought to be a rare cause of stroke, particularly in the absence of trauma, and the diagnosis was usually not made until the postmortem examination.[1]
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Neck trauma is strongly associated with extracranial VAD, because the vertebral artery is vulnerable to mechanical injury at C1 to C2 as it leaves the transverse foramen of the axis vertebra and suddenly turns to enter the intracranial cavity.[8]
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[13] The clinical manifestations include severe neck pain, mostly in the occipitocervical area followed after a variable interval by ischemic symptoms. In some patients there may not be any ischemic symptoms. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features.[14]
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[16] Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes. Our patient manifested symptoms three days after a chiropractic therapy session, developing high intracranial pressure syndrome due to the closure of the fourth ventricle after right cerebellar ischemia. Besides both verteral arteries flow were interupted, a very rich collateral anastomotic circulation allowed blood flow for the brain stem and the left cerebellar hemisphere, avoiding a more severe manifestation.[1]
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Several radiographic features suggest dissection, including the appearance of a flap, tapering stenosis or pseudoaneurysm on angiography, and the imaging of the arterial wall showing intramural blood. Catheter angiography has been the gold standard for the diagnosis of arterial dissections.[21]
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[24] The most common finding on angiography is the one called “string sign”, a long segment of narrowed lumen. The pathognomonic features of dissection, such as an intimal flap or a double lumen, are found in less than 10% of cases. Artery may be tappered by occlusion of thr lumen, but sometimes aneurysmal dilatations are also founded.[25]
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The choice of antiplatelet drug or anticoagulant drug was at the discretion of the local physician. Antiplatelet treatments included aspirin, dipyridamole, or clopidogrel alone or in combination.[14]
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[22] For patients assigned to anticoagulation, treatment with heparin (either unfractionated heparin or a therapeutic dose of low-molecular weight heparin) was followed by warfarin, aiming for an international normalized ratio of 2–3. Novel oral anticoagulants were not used.[19]
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[22] Some studies compared the antiplatelet and anticoagulant treatments for extra cranial carotid and vertebral artery dissection, showing that recurrent stroke at 3 months is rare, with no significant difference between the two treatments.[14] Although more strokes occurred in the antiplatelet group than in the anticoagulant group, this difference was counterbalanced by one major subarachnoid hemorrhage in the anticoagulant group.[19]
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[22] We chose antiplatelet therapy, considering the risk of bleeding after surgical procedure.
The prognosis depends on many factors, but the severity of the neurological deficits at the time of presentation is directly related to the functional outcome.[1]
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[21] Most patients with extracranial dissection do remarkably well if they survive the initial crisis. About 88% of patients show complete clinical recovery at follow-up. However, the overall risk of death, recurrent transient ischemic attacks, or stroke is of ∼ 10%.[21] Even though our patient had bilateral vertebral artery dissection, she had a good outcome because the collateral circulation supplied irrigation for the vertebral and basilar arteries territory.
