Stroke following chiropractic manipulation of the cervical spine

We analyzed the clinical course and neuroradiological findings of ten patie nts aged 27-46 years, with ischemic stroke secondary to vertebral artery di ssection (VAD; n = 8) or internal carotid artery dissection (CAD; it = 2), all following chiropractic manipulation of the cervical spine. The followin g observations were made: (a) All patients had uneventful medical histories , no or only mild vascular risk factors, and no predisposing vascular lesio ns. (b) VAD was unilateral in five patients and bilateral in three. VAD was located close to the atlantoaxial joint in all eight patients and showed a dditional involvement of lower sections in six, as well as temporary occlus ion of one vertebral artery in three. (c) Nine of ten patients had brain in farction documented by magnetic resonance imaging or computed tomography. ( d) Onset of symptoms was immediately after the manipulation (n = 5) or with in 2 days (n = 5). (e) Progression of neurological deficits occurred within the following hours to a maximum of 3 weeks. (f) Maximum neurological defi cits were severe in nine of ten patients. (g) Outcome after 4 weeks-3 years included no or mild neurological deficits in five patients, marked deficit s in three, persistent locked-in syndrome in one, and persistent vegetative state in one. (h) Informed consent was obtained in only one of ten patient s. Thus, patients at risk for stroke after chiropractic manipulation may no t be identified a priori. Neurological deficits may be severely disabling a nd are potentially life threatening.