J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.349 on 1 March 1987. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1987;50:349-353 Short report Dissecting aneurysms of the vertebral arteries following cervical manipulation: A case report JOHN W DUNNE, G NEIL CONACHER,* MAKHAN KHANGURE, CLIVE G HARPERt From the Departments ofNeurology, Neuropathology, Radiology, Royal Perth Hospital, Perth, Australia SUMMARY Neck manipulation may uncommonly be associated with serious and even fatal vascular complications. Although well recognised, the nature of the vascular injury has only rarely been directly established by pathological examination. The case is reported of a 43-year-old man who died following neck manipulation, and in whom multiple dissecting aneurysms within both verte- bral arteries were demonstrated radiologically and found at necropsy. Bilateral dissecting aneurysms were found both at the level of atlanto-axial articulation and close to the origins of the vertebral arteries. No predisposition was found, other than early atheroma consistent with the patient's age. Protected by copyright. Alternative medicine, including chiropractic and oste- mainly having been adduced from radiographic opathy, enjoys an ever-increasing popularity. The findings. The nature of the vascular injury has only Australian Health Survey for 1977-1978 estimated rarely been directly established by pathological exam- that in a four-week period just over 2% of Austra- ination,2 3 4 14 thus prompting this report. lians had consulted a chiropractor, naturopath or We describe the case of a 43-year-old man who died osteopath.' However, an increasing number of following neck manipulation and in whom multiple reports indicate that spinal manipulation can be asso- dissecting aneurysms within both vertebral arteries ciated with serious and even fatal vascular2-14 and were demonstrated radiographically and found at non-vascular injuries. Vascular injury related to neck necropsy. manipulation has mainly involved the vertebral and basilar arteries2- 10 13 14 although several reports Case report describe injuries to the internal carotid artery."'12 Thrombosis occlusion of the vertebral and A 43-year-old truck driver presented with a three-month his- and tory of intermittent headache and neck discomfort associ- basilar- - 4 traumatic artery arteries,2 vertebral ated with long-distance driving. He went to a naturopath, http://jnnp.bmj.com/ pseudo-aneurysm,45 haemorrhage from perforation since he had had similar symptoms treated successfully by of the vertebral artery,4 and vertebral artery dis- local manipulation 3 years before. Immediately after a ther- secting aneurysm6 have all been reported, these apeutic twisting of the neck he experienced the sudden onset of vertigo, with transient loss of consciousness followed by persistent vertigo, vomiting, and oscillopsia. There was no previous history of similar episodes, hypertension, or other Address for reprint requests: Dr JW Dunne, Mayo Clinic, 200 1st significant illness. Street S.W.. Rochester, MN 55905, USA. Upon examination 6 hours after the onset he was drowsy, but orientated and co-operative. There was no neck stiffness on October 2, 2021 by guest. *Present address: Kingston Penitentiary Treatment Center, or photophobia. A slurring dysarthria, rotatory nystagmus Kingston. Ontario. Canada. in the primary position, and mild bilateral upper limb intention tremor were present. The patient was able to sit +Present address: Department of Pathology, University of Sydney, but was unwilling to stand because of vertigo. There were no Sydney NSW 2006. Australia. cranial or neck bruits. Pulse was 70/minute and regular, and heart sounds were nor- Received 20 December 1985 and in revised form 4 June 1986. blood pressure 130/70mmHg, Accepted 19 June 1986 mal. Radiographs of the cervical spine showed minimal 349 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.349 on 1 March 1987. Downloaded from 350 Dunne, Conacher, Khangure, Harper ?z..:: zMt: 'A I. ....... .....;. .. ; Protected by copyright. ?t | ... :.. I:. w|11 1_l_ *5 ...q _sr-' :.:. *: .: .:>s... Sr IS3XE a"e}: :) http://jnnp.bmj.com/ ..?i. * .W.'.}.*e L. .:'' . .:!: ^_ __ on October 2, 2021 by guest. ? _. s:_ . __ Fig 1 (a) Subtraction print, lateral and AP, ofright vertebral artery. The traumatised segment (between arrows) shows narrowing ofthe lumen and irregularity ofthe vessel wall, suggesting a dissection. (b) Subtraction print, lateral and AP, ofleft vertebral artery. In addition to the narrowed vessel lumen (curved arrows) there is a pseudo-aneurysm (open arrow). J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.349 on 1 March 1987. Downloaded from Dissecting aneurysms of the vertebral arteries following cervical manipulation: a case report 351 osteophytic lipping of the lower cervical vertebrae but no required intubation and ventilation. He developed a flaccid other abnormalities..Cranial CT scan with and without con- quadriplegia and hypotension. Initially brainstem reflexes trast was normal. Plasma urea and electrolytes, blood sugar were present, however these were lost over the next 4 hours. level and full blood picture were normal. Syphilis and Neurological examination a further day later confirmed that hepatitis-B serology were negative as was serum anti-nuclear the patient showed the criteria for brainstem death and antibody. advanced life support was discontinued. Over the next 24 hours the patient remained drowsy with persistent generalised headache. He developed moderate Pathologicalfindings neck stiffness, conjugate deviation of the eyes to the left, a The necropsy was performed by Dr J Hilton, forensic right horizontal gaze palsy and impairment of upgaze. Hori- pathologist. General findings were of extensive hypostatic zontal jerk nystagmus was noted on left lateral gaze. Tone pneumonic consolidation, congestion and oedema. The and deep tendon reflexes of the right arm and leg were aug- aorta showed minimal atheroma laid down in streaks, but mented, although there was no obvious weakness and plan- other major arteries appeared healthy. The brain and spine tar responses remained flexor. were referred to the Department of Neuropathology, Royal Occlusion or dissection of the vertebral arteries was sus- Perth Hospital, for detailed studies. pected and angiography was performed. Both common Macroscopic examination of the brain showed generalised carotid and vertebral arteries were catheterised via a femoral swelling with flattening of the gyri. The pons, superior approach. The carotid studies were normal. The vertebral medulla, and posterior portion of the left cerebellar hemi- arteries both showed abnormalities extending from mid C2 sphere were markedly softened, and there was bilateral ton- to the level ofthe foramen magnum. On the right side (fig Ia) sillar herniation through the foramen magnum. Extensive the involved segment (between arrows) showed narrowing of necrosis involving both brainstem and cerebellum was the opacified lumen and irregularity of the vessel wall. On confirmed on microscopic examination. Ischaemic neuronal the left (fig lb) there were similar changes, but in addition change was evident in the carotid arterial territories, but there was a pseudo-aneurysm (open arrow). The posterior without frank necrosis. inferior cerebellar arteries (PICAs) were normal as was the The vasculature at the base of the brain was normal with basilar artery. These appearances were consistent with bilat- no macroscopic evidence of atheroma. The carotid arteries eral dissections. were also normal throughout their lengths. The vertebral The patient was treated conservatively. Forty-two hours arteries were dissected out from their origins at the sub- Protected by copyright. after neck manipulation he had a respiratory arrest and clavian arteries by removal of the anterior arches of the for- \ 4. vi http://jnnp.bmj.com/ on October 2, 2021 by guest. w; .: .! it,. .. '^: z.}'S ^!QE *: . X };. e Fig 2 Sec tion ofthe right vertebral artery at the atlanto-axial articulation, stained to show elastic tissue. Thrombus is seer: within the dissection which lies between the tunica media and adventitia. Elastica van Gieson, x 10. 4.=S .;' J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.349 on 1 March 1987. Downloaded from 352 Dunne, Conacher, Khangure, Harper amina transversaria. The right vertebral artery showed areas transverse foramina. Such proximal dissections may of contusion of the adventitia at 7 cm and 10-12cm from its be missed in radiographic examinations because of origin. The arteries were sectioned transversely at 1 cm inter- their position. Perhaps because of this, and the infre- vals. Macroscopically, dissecting aneurysms were seen in the quency of pathological examination of the entire right vertebral artery at 0-5 cm and 9-12 cm from its origin, length of the vertebral arteries, extra-cranial vertebral and in the left vertebral artery at 1-3 cm and 1 1-12 cm. The arterial walls were intact in areas between. Thrombus was artery dissections have only rarely been described."' present within the dissections with occlusion of the original Controversy persists as to what degree are cerebral lumina at the level of the atlanto-axial articulation, artery dissections spontaneous or traumatic. Some 11-12cm from the origins of the arteries (fig. 2). Contrast have related all such cases to trauma, often as min- medium from post-mortem radiographic studies was