1414 - Cracking Necks, Backs, and Blood Vessels - A Case of Bilateral Vertebral Artery Dissection in a Multiple Sclerosis Patient Following Chiropractic Manipulation

Case Diagnosis: Ischemic stroke 2/2 vertebral artery dissection

Case Description: 40yoF with PMH of migraines, anxiety, and recently diagnosed MS presented to the ED with complaints of R-sided paresthesias. NIHSS was 2 for moderate R-sided sensory deficits and mild ataxia with finger-to-nose testing of RUE. CTA/CTP negative for large vessel occlusion or perfusion mismatch. Admitted for concerns of active MS lesion vs stroke. On afternoon of admission, patient had new RUE and RLE flaccidity, R facial droop, and L tongue deviation. Brain MRI showed acute ischemia in L medulla, prompting further evaluation with MRI dissection protocol, which revealed acute dissection of V3/V4 segment of L vertebral artery and dissection of mid P2 portion of R vertebral artery. It was not until the dissection was discovered and further questioning that the patient revealed that she had had chiropractic manipulation of her neck 2 days prior to start of symptoms.

Discussions: Vertebral artery dissection (VAD) is a rare, but known complication of chiropractic manipulation. An estimated 1 in 20,000 spinal manipulations results in vertebral artery dissection/aneurysm. This case is of particular interest because it involves a recent MS diagnosis. Symptoms of VAD most often include dizziness, poor balance, weakness, numbness, and headache. However, these symptoms can present subtly and by themselves are nonspecific. In this particular case, it was unclear upon initial workup whether the patient’s symptoms could be attributed to her recently diagnosed MS or to stroke, which would be unusual for a patient of her age with no known comorbidities or risk factors.

Conclusions: Though uncommon, ischemic stroke represents a preventable, devastating consequence of VAD secondary to chiropractic manipulation. In patients with conditions such as MS, symptoms of VAD may not be easily discernible. As such, it is crucial for providers to educate patients on signs/symptoms of VAD if they are choosing to undergo chiropractic manipulation.