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Young patients may develop central nervous system infarcts following cardioembolic events, paradoxic emboli through intracardiac shunts, vasculitis, and vascular trauma in the neck. We describe a patient who developed posterior circulation symptoms following chiropractic manipulation of her neck. This case illustrates the hazards associated with neck manipulation and the potential for good outcomes in these patients if they develop a stroke syndrome.
CASE DESCRIPTION
A 38-year-old female schoolteacher with no significant past medical history presented with headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia for 2 to 3 weeks. These symptoms started after a visit to her chiropractor and neck manipulation. Her symptoms were further exacerbated by hanging decorations from the ceiling at work. Her level of consciousness gradually decreased over the same time period. She was not taking any medications on admission and denied allergies and use of tobacco, alcohol, or illicit drugs. She was married and had two children. On examination, she was drowsy but aroused with sternal rubs. Her temperature was 97.6°F; heart rate, 71 beats per minute; blood pressure, 144/92 mm Hg; and respiratory rate, 18 breaths per minute. She was disoriented and followed simple commands poorly. She demonstrated nystagmus to the left. She moved all extremities but had left-sided weakness (3/5) with hyperreflexia. Cardiac, respiratory, and abdominal examinations were within normal limits. Her white blood cell count was 13 k/?L; hemoglobin, 13.7 g/dL; and platelets, 286 k/?L. Renal and liver function tests, electrolytes, and coagulation times were within normal limits.
A computed tomography (CT) scan of her head performed on admission showed a non-contrast-enhancing process involving the inferior half of the left cerebellar hemisphere (). There was extensive mass effect with displacement, distortion, and compression of the fourth ventricle causing moderate acute obstructive hydrocephalus and displacement of the cerebellar vermis to the right. There was mild cerebellar tonsillar herniation. No hemorrhage was present. Magnetic resonance imaging (MRI) on day 2 showed an acute left cerebellar infarct involving the posterior inferior cerebellar artery and the anterior inferior cerebellar artery territories with hydrocephalus and pneumoventricle (). Magnetic resonance angiography (MRA) performed on day 3 showed severe narrowing and low flow in the intracranial segment of the left distal vertebral artery near the basilar artery (). The right vertebral artery, basilar...