INTRODUCTION

Stroke is a worldwide leading cause of death and disability, and is defined as focal neurological deficit due to disrupted blood flow to the brain.1 Symptoms may include a sudden feeling of weakness, numbness, paralysis, speech and language issues, vision problems, dizziness, and trouble walking.2 Cervical artery dissection (CAD) most commonly occurs when a tear in the innermost layer of a cervical artery allows blood to flow between it and the middle layer (tunica intima and tunica media, respectively), creating a false lumen and hematoma.3 CAD can occur as either vertebral artery dissection (VAD) or internal carotid artery dissection (ICAD). Both can have a wide range of presentation and consequence, ranging from asymptomatic to stroke.3 Several large and well-publicized studies have previously demonstrated the lack of a causative relationship or an increased risk of stroke with chiropractic care, and suggested that patients experiencing an evolving stroke might unknowingly present to a chiropractor for treatment.4–8 Yet multiple case studies detail stroke symptoms that manifested immediately following cervical spinal manipulation (CSM).9–11

In attempting to reconcile these seemingly contradictory findings, one theory suggests that the two most common symptoms of CAD, neck pain and headache, cause the patient to seek chiropractic care,4,6,7 the symptoms are not recognized as non-musculoskeletal in origin, and CSM results in a thrombotic or thromboembolic event by the repositioning or dislodging, respectively, of a clot that had formed due to CAD.12

It is imperative for chiropractors and other healthcare professionals performing CSM to be adequately trained in the presentations of both stroke and CAD so that appropriate and timely referrals can be made when patients present with seemingly innocuous symptoms that may be attributable to serious and life-threatening non-musculoskeletal causes.

This paper describes the case of an adult female with a chief complaint of neck pain accompanied by headache who sought chiropractic care. The chiropractor suspected VAD and made an appropriate referral, ultimately leading to a favorable outcome for the patient.

CASE REPORT

Two Years Prior Presentation

Two years before the visit on which this report focuses, a 23-year-old female initially sought chiropractic care for chronic neck pain and headache. Past medical history included diagnoses of fibromyalgia and lumbar disc herniation. She stood 5’6" and weighed 155 pounds. Vital signs were within normal limits with respiratory rate at 15, blood pressure at 116/72, and heart rate at 70. She denied any syncope, tremors, dizziness, numbness, loss of feeling, paresthesia, loss of strength, loss of coordination, or trouble maintaining balance.

Her neck pain was reported as starting in the upper trapezius region bilaterally and radiating to the neck and head. She described it as aching and rated at 7/10 on a scale from 0 to 10, with 10 being the worst pain imaginable. Soft tissue palpation revealed hypertonicity in the cervical paraspinal musculature, as well as myofascial trigger points in the trapezius and sternocleidomastoid muscles bilaterally. Osseous palpation revealed joint restriction at C5 and C7. Range of motion testing showed decreased cervical flexion, right and left lateral flexion, and right and left rotation. Orthopedic test findings are listed in Table 1.

Table 1.Orthopedic Tests
Test Result
Cervical Compression Negative
Foraminal Compression Negative bilaterally
Shoulder Depression Positive for local muscle pain bilaterally
Soto-Hall Positive for local muscle pain
Cervical Distraction Negative
O’Donoghue’s Positive for pain with resisted motion bilaterally

She was diagnosed with cervical segmental dysfunction as well as cervicogenic headache. Treatment consisted of spinal manipulation to the cervical region, along with electric muscle stimulation and hot packs. She was treated 8 times over a period of 3 weeks, reported notable improvement, and was released from care.

Current Presentation

Two years later, the now 25-year-old patient returned to the same chiropractic clinic with neck pain and headache, citing her previous success with chiropractic care for those complaints. She reported that 9 days prior, after working on her computer, she had experienced debilitating neck spasm and migraine so severe that she reported to the emergency department of a local hospital. The hospital performed a cervical spine computed tomography (CT) scan without contrast. The radiology report stated that no cervical spine fracture was evident. The patient improved and was released.

Upon presenting to the chiropractic clinic, she reported lingering headache and neck pain, mostly right-sided, and stated that she was having trouble seeing street signs while driving. Further questioning revealed recent episodes of dizziness, nausea, and blurry vision, as well as sweating that occurred when certain neck movements caused pain. She denied any difficulty walking or speaking, but reported occasional facial twitches over her right cheek and a recent feeling of general fatigue.

SHe stood 5’6" and weighed 160 pounds. Vital signs were within normal limits, with respiratory rate at 15, blood pressure at 110/85, and heart rate at 95. The neck pain was located on the right and radiated to the right shoulder region. It was described as sharp and aching and rated at 9/10. The headache was described as an aching on the right side and rated at 8/10. Cervical range of motion was decreased in all directions with pain on lateral flexion and rotation bilaterally. Cervical extension produced dizziness. Neurological examination findings are listed in Table 2.

Table 2.Neurological Examination
Test Result
Cranial Nerve Pupils were equally round and reactive to light; able to follow H pattern without nystagmus. Facial asymmetry was observed when the patient smiled; the right cheek did not elevate equally, suggesting cranial nerve VII involvement. Tongue protrusion did not deviate right or left.
Romberg’s Positive, patient lost balance.

Due to the aforementioned findings, the chiropractor suspected VAD and referred the patient to the emergency department of a local hospital different from the one she had previously visited. He also called the emergency room and spoke to the attending physician, alerting him of the patient’s imminent arrival, the suspicion of VAD, and a recommendation to perform either magnetic resonance angiography (MRA) or CT with contrast.

The hospital performed a CT angiogram (CTA) with contrast of the head and neck. The diagnostic imaging report stated the following:

  • No evidence for anterior circulation stenosis or dissection.

  • There is a tiny right vertebral artery pseudoaneurysm at the level of the skull base (C2 level) consistent with a tiny focal dissection of the distal right vertebral artery. No other posterior circulation abnormality is noted.

  • On the contrast-enhanced whole brain imaging, no focal abnormality is identifiable to indicate infarction or ischemia.

The patient was diagnosed with vertebral artery dissection and transported to a larger regional hospital for care. The following day, MRA of the neck without contrast, magnetic resonance imaging (MRI) of the brain without contrast, CTA stroke protocol with contrast, and CTA of the head with contrast were performed. Diagnostic imaging reports stated the following:

MRA neck without contrast

  • 2mm laterally directed pseudoaneurysm arising from the distal V2 segment of the right vertebral artery at the C2-C3 level of the spine.

  • There is also smooth, mild narrowing of the distal V1 and proximal V2 segments of the right vertebral artery.

  • The findings are consistent with vertebral artery dissection.

  • Associated intramural hematoma is suspected on the axial T1 fat saturated sequence.

  • Unremarkable appearance of the visualized portions of the left vertebral and bilateral common carotid and cervical internal carotid arteries.

MRI brain without contrast

  • No acute infarction or other acute intracranial abnormality on the unenhanced brain MRI.

CTA stroke protocol

  • 2mm pseudoaneurysm again arising from the right vertebral artery as previously described. No new abnormality of the vasculature in the neck compared with the prior MRA examination.

  • No intracranial arterial occlusion.

CTA head with contrast

  • No evidence of acute hemorrhage, hydrocephalus, or herniation.

  • No acute transcortical infarct.

The patient was treated with anticoagulant therapy, initially intravenously and later orally. Six weeks later, MRA of the neck without contrast was again performed. The diagnostic imaging report stated the following:

  • Improved appearance of the right vertebral artery as compared to the prior studies, currently without irregularity or stenosis. The previously noted pseudoaneurysm is not clearly visualized. There is no definite intramural hematoma identified.

The patient made a full recovery. A clinical timeline of events is presented in Table 3 and imaging results are summarized in Table 4.

Table 3.Clinical Timeline of Patient Events
Date/Timing Event
Initial Presentation (Age 23) Patient presents to chiropractor with chronic neck pain and headache. Diagnosed with segmental dysfunction and cervicogenic headache. Treated 8 times over 3 weeks with improvement and released from care.
2 Years Later (Age 25) Patient develops severe neck spasm and headache after working on computer. Visits local hospital ER; CT (non-contrast) performed; no fracture found; discharged.
9 Days After ER Visit Patient presents to same chiropractor with persistent right-sided neck pain and headache, visual disturbances, dizziness, and other neurologic signs. VAD suspected.
Same Day Chiropractor refers patient to different ER; CTA confirms right vertebral artery pseudoaneurysm consistent with VAD.
Next Day Patient transferred to larger hospital. Undergoes MRA, MRI, and additional CTA imaging confirming VAD.
6 Weeks Later Follow-up MRA shows resolution of pseudoaneurysm and no evidence of intramural hematoma or stenosis. Full recovery.
Table 4.Summary of Diagnostic Imaging Findings
Imaging Type Timing Findings
CT (non-contrast) Initial ER visit No cervical spine fracture evident
CTA (contrast) Second ER visit Tiny right vertebral artery pseudoaneurysm at skull base (C2); consistent with focal dissection
MRA (non-contrast) Day after CTA 2mm pseudoaneurysm from distal V2 of right vertebral artery; narrowing of V1/V2; suspected intramural hematoma
MRI (non-contrast) Day after CTA No acute infarction or other intracranial abnormality
CTA Stroke Protocol (contrast) Day after CTA 2mm pseudoaneurysm as before; no intracranial arterial occlusion
CTA Head (contrast) Day after CTA No hemorrhage, hydrocephalus, herniation, or infarct
Follow-up MRA (non-contrast) 6 weeks later Improved artery appearance; no pseudoaneurysm or hematoma; no stenosis

DISCUSSION

Cervical artery dissection is a rare, but serious condition that can have life-altering or life-threatening consequences. While it may not be the first diagnosis that comes to mind in a patient with headache or neck pain, CAD is one of the leading causes of stroke in otherwise healthy young and middle-aged adults. It is estimated to account for up to 25% of all strokes in individuals under the age of 50.13 Although the overall annual incidence in the general population remains low (estimated at 2.43 per 100,000 person-years for ICAD, and 2.01 per 100,000 person-years for VAD), the disease burden is disproportionately high due to the common patient demographic and potentially serious outcomes.13 In the cited population-based retrospective observational cohort study, data covering the most recent years report an annual incidence rate of 8.93 per 100,000 person years for CAD, an increase likely attributable to the increased use of vascular imaging. Symptoms can be subtle and mistaken for more benign conditions: a dull neck ache, a different than normal headache, or transient visual disturbances. These nonspecific symptoms can delay diagnosis, making it essential for clinicians to maintain a high index of suspicion, especially in the context of CSM.

The idea that CSM can cause stroke appears often in both media and medico-legal discussions. One goal of this case report is to reframe the conversation around diagnostic vigilance rather than causal blame. Chiropractors may be the first providers to see patients with neck pain or headache due to CAD; not because manipulation causes it, but because patients seek relief from those symptoms. It is an example of protopathic bias, when early symptoms of a disease (for example, neck pain and headache from CAD) prompt the patient to seek care. This can lead to a mistaken conclusion that the treatment caused the disease, when in fact the disease’s early symptoms triggered the treatment, in this context CSM, which may then reposition or dislodge a thrombus leading to a stroke.12

If a dissection is overlooked, the consequences for both the patient and the physician can be catastrophic. The importance of a thorough history and examination cannot be overstated. Unfortunately, no standardized criteria have been established to screen for CAD. Several strategies and tools to exclude cervical artery dissection have been proposed14,15 but they fail to account for the documented occurrence of asymptomatic CAD,16 the existence of which further muddles the diagnostic water. Imaging modalities such as MRA and CTA can visualize dissections before the onset of stroke, but sending every patient with a headache and neck pain for such a scan would be impractical, the equivalent of a medical doctor sending every patient with a cough for a chest CT to rule out lung cancer before treatment.

The clinician is left in a position of uncertainty, where best current evidence suggests relying not only on well-established signs and symptoms of stroke (weakness, numbness, paralysis, speech and language issues, vision problems, dizziness, and trouble walking),2 but also on the emerging understanding of the genetic and environmental risk factors for CAD. Hypertension, migraine, hyperhomocysteinemia (elevated levels of homocysteine in the blood), and familial history of arterial dissection have all been linked to an increased risk of CAD.17–19 An established association also exists between CAD and connective tissue disorders (CTDs) such as Ehlers-Danlos syndrome and Marfan syndrome.20–22 Recently, a link between cervical artery dissection and fluoroquinolone medication has been proposed.23 Fluoroquinolones are a class of broad-spectrum antibiotics (ciprofloxacin, levofloxacin, etc.) used to treat bacterial infections. Due to their effects on the integrity of collagen and the extracellular matrix, fluoroquinolones are suspected to contribute to an increased risk of CAD.24–26

In this case, it is unknown whether the patient had recently used fluoroquinolone medication, but her history did reveal a prior diagnosis of fibromyalgia. It is not unreasonable to suspect that this patient may have an undiagnosed connective tissue disorder, as fibromyalgia is poorly understood and an overlap exists in the diagnostic approach and symptomatic features of fibromyalgia and several CTDs.27,28

In addition to the dizziness, nausea, and blurry vision reported by the patient, several other factors in the history of the current complaint raised the clinician’s suspicion. The successfully treated prior complaint involved bilateral neck pain, whereas the current complaint was 1-sided with a different description of the pain, “achy” vs “spasm”, respectively. Furthermore, the patient described the current headache as a “severe migraine.” Without a prior diagnosis or history of migraine, it is reasonable to suspect that “migraine” was simply a term the patient used to describe a new and more intense headache than she had ever experienced. Clinicians must be aware that VAD can mimic migraine with aura, especially when presenting with visual disturbances, nausea, or paresthesia. However, unlike migraine, VAD-related symptoms often emerge abruptly and are frequently accompanied by focal neurological signs. In the absence of a documented migraine history, the sudden onset of a severe, unfamiliar headache with accompanying neurologic features should raise suspicion for a vascular event as opposed to a primary headache disorder.29

Given that the patient had an established history of successful treatment for complaints of neck pain and headache by the same chiropractor, the accurate diagnosis of VAD could have been readily overlooked. Additionally, the patient had already reported to a hospital and was discharged without intervention, further increasing the likelihood that a practitioner might dismiss the chance of severe pathology. Notably, the first hospital only performed CT without contrast. When CAD is suspected, proper imaging (MRA or CTA) is crucial.

After receiving the appropriate medical treatment, the patient fully recovered with no lingering symptoms or life-altering effects. She has since returned to the chiropractic clinic several times for treatment of varied musculoskeletal complaints.

Limitations

This is a single-patient case report, and the results may not be generalizable to other individuals presenting with similar conditions.

CONCLUSION

This report highlights the case of an existing patient who had previously been treated for symptoms of neck pain and headache, returning to a chiropractic clinic for treatment of what seemed like a familiar episode. Due to several key differences in the history and patient presentation, the chiropractor suspected cervical artery dissection and made an appropriate referral for emergency services before treating the patient, who subsequently received medical intervention and experienced a positive outcome. Without the existence of a standardized screening tool or protocol, it is paramount for practitioners to be acutely aware of the varying signs and symptoms, as well as the genetic and environmental risk factors, of cervical artery dissection.

Written consent for publication was obtained from the patient.

COMPETING INTERESTS

The authors declare no competing interests.