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Pica artery dissection survival6/21/2023 ![]() ![]() 2, 4)Īny part of the carotid artery and VA can be injured, depending on the direction, degree, and force of cervical manipulation. 3, 10) Focal ischemia occurs several hours or weeks after such a dissection, which occurs either because blood flow is reduced from the arterial blood supply or because the risk of thrombosis and embolism is increased due to the turbulence and irregularities in the vessel wall at the dissected location. As a result, blood flow is stopped and thrombosis or distal embolism of the dissection site appears. VA dissection can injure the intima or media of the vessel, causing hematoma formation in the subadventitial or subintimal layer. 9) Rates of VA dissection following a cervical manipulation are rarely reported, so the exact incidence is unknown. 1, 7) This procedure can injure the neck vessels, typically representing the cervical segment of the VA, and this could produce a cerebral stroke and disability symptoms. To treat cervical and lumbar pain, chiropractic manipulation is considered an alternative therapy. So it is unlikely that the infarction was caused by cardiac thrombosis or other vascular abnormalities. And doppler ultrasonography did not reveal atherosclerosis of both internal, external carotid arteries. There was no embolic source in the heart transthoracic echocardiogram and heart CT. After angiography, the patient was admitted to a neurological intensive care unit, and he received antiplatelet therapy with the use of Aspirin® 100 mg/day (Bayer AG, Leverkusen, Germany). And it showed the retrograde blood flow to the left VA to the V2 segment (C1 level) and also showed the occlusion of left PICA ( Figure 2A and B). Transfemoral cerebral angiography revealed the occlusion of left VA at V1/2 junction. RCCA: right common carotid artery, RVA: right vertebral artery, LCCA: left common carotid artery. (E) MR angiography reveals the obstruction in the left proximal vertebral artery at the level of the left subclavian artery (empty arrow) with retrograde flow (arrow head). (D) Gradient-echo image of the brain MR imaging suggests the blood clot in the PICA (black arrow). (B) Brain magnetic resonance (MR) imaging (diffusion-weighted image) and (C) brain MR imaging (apparent diffusion coefficient map) reveals an acute infarction in the left posterior inferior cerebellar artery (PICA) territory. Initial brain computed tomography does not show the abnormal density in the cerebellum. ![]() MR angiography revealed complete occlusion of left VA with retrograde blood flow ( Figure 1E). Gradient echo image suggested blood clot in left PICA ( Figure 1D). But magnetic resonance (MR) imaging (MRI) revealed acute infarction in the left PICA territory ( Figure 1B and C). Brain computed tomography (CT) showed normal cerebellar parenchyma ( Figure 1A). Upon imaging, skull and cervical spine radiographs were normal. He initially denied any trauma, but remembered severe pain when he underwent a cervical chiropractic manipulation about two weeks prior. Routine laboratory tests of blood and electrolytes, were within normal ranges. He had no underlying disease and no medication use. Blood pressure was 150/80 mmHg, and pulse rate was 88 beats/min with normal sinus rhythm of electrocardiography. Finger to nose, heel to shin and rapid alternating movement test showed that cerebellar function was impaired on the left side, with intact function of the right side. At the time of admission, the patient showed alert consciousness, but neurological examinations showed the signs of cerebellar dysfunction. The possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.Ī 39-year-old man visited the emergency room with a dizziness and balance impairment that occurred 6 hours before. Three weeks later, he was discharged without any sequelae. He was treated with antiplatelet therapy. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA V1/2 junction) as a result of the dissection of the VA. Two weeks ago, he was treated by a chiropractor for intermittent neck pain. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. We describe the case of a patient who had infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. ![]()
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