Internal carotid artery dissection following chiropractic treatment in a pregnant woman with systemic lupus erythematosus

Morton Chiropractic & Manual Therapies 2012, 20:38 Internal carotid artery dissection followingchiropractic treatment in a pregnant woman withSystemic Lupus Erythematosus A case of internal carotid artery dissection in a pregnant woman with Systemic Lupus Erythematosus (SLE)immediately following chiropractic treatment is presented. The literature regarding complications of neckmanipulation during pregnancy, spontaneous dissection of craniocervical arteries in pregnancy and thepostpartum period, and dissection of craniocervical arteries in SLE are reviewed. To the best of the author’sknowledge, this is the first case of carotid artery dissection following chiropractic treatment in a pregnant womanpublished in the literature.
Keywords: Carotid dissection, Neck manipulation, SLE, Pregnancy monthly since the age of 14 years. The frequency of Dissection of the internal carotid artery accounts for ap- headache was unchanged during pregnancy. In addition proximately 20% of cases of ischaemic stroke in young she had a history of migraine characterised by unilateral adults. A population-based study reported the average frontal headache, the last episode of which had been 6 annual incidence rate for spontaneous internal carotid weeks earlier. There was no recent history of viral illness artery dissection was 1.72 per 100 000 individuals and no family history of stroke. The subjects history Several vascular and connective tissue disorders have was also significant for Systemic Lupus Erythematosus been associated with dissection, in particular migraine, (SLE) diagnosed twelve years earlier, complicated by fibromuscular hyperplasia and vascular Ehlers-Danlos renal involvement treated with azathioprine and prednis- syndrome. In addition, a number of physical activities one, hypertension managed with labetalol, and episodes have been associated with dissection. It remains unclear of deep vein thrombosis and pulmonary embolism.
as to whether chiropractic neck manipulation is asso- She was heterozygous for prothrombin gene mutation ciated with craniocervical artery dissection. This paper but did not have a lupus anticoagulant or anticardiolipin describes a case of internal carotid artery dissection fol- lowing chiropractic treatment in a pregnant woman with Immediately after receiving treatment the subject Systemic Lupus Erythematosus. The possible contribut- noted severe right sided anterior neck pain, and rapidly ing factors in this case are discussed.
developed ipsilateral Horner’s syndrome. It was not pos-sible to obtain exact information regarding the nature ofthe chiropractic treatment; though from the subject’s de- scription it is likely that spinal manipulation was given.
A thirty-one year old woman, pregnant at 16 weeks ges- Magnetic resonance imaging (MRI) revealed extensive tation, presented to a chiropractor for treatment of oc- dissection of the right internal carotid artery, extending cipital headache. She had suffered with intermittent from 5 cm distal to the carotid bulb to the horizontal bilateral occipital muscle tension headaches occurring intrapetrous segment. The subject was admitted to theintensive care unit and treated with intravenous heparin Correspondence: QLD Diabetes Centre Mater Health Services Raymond Terrace, South and subsequently low-molecular weight heparin. A flare in SLE was evidenced by a rise in blood pressure, a slight Full list of author information is available at the end of the article 2012 Morton; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.
Morton Chiropractic & Manual Therapies 2012, 20:38 deterioration in maternal renal function, increasing pro- manipulation. These included cerebellar infarction, ver- teinuria and a fall in platelet count. Four days after the tebral artery occlusion, odontoid fracture and a cervical onset of neurological symptoms intrauterine foetal de- epidural haematoma. They concluded that significant mise was noted. The patient was subsequently anticoa- life-threatening injuries were rare following spinal ma- gulated with warfarin for six months. Follow-up MRI six nipulation during pregnancy and the postpartum period, months later revealed a focal false aneurysm of the right and that further research into the frequency of adverse internal carotid artery. The Horner’s syndrome persists events and efficacy of spinal manipulation therapy in this one year after the initial presentation.
The controversy regarding the possible association be- tween cervical spine manipulation and neurovascular Only one case of antepartum internal carotid artery dis- complications remains unresolved and continues to be section has been reported of which the author is aware debated [Conclusive evidence is difficult to obtain Maderia et al described a 38 year old woman in her because of the rarity of adverse events. A population- fifth pregnancy at 21 weeks gestation who presented based case-control and case-crossover study found no with headache and a spontaneous left internal carotid ar- evidence of excess risk of vertebrobasilar stroke asso- tery dissection involving the petrous and cavernous seg- ciated with chiropractic care compared with primary ments on MRI. In addition 22 cases of postpartum care physician visits [recent retrospective case- carotid artery dissection have been reported There control study, however, found an odds ratio of 12.8 was an even distribution of vaginal and caesarean deliv- (p = 0.009) for neck manual therapy in individuals less eries, the time from delivery to onset of symptoms ran- than 55 years of age presenting with craniocervical arter- ged from 2 – 21 days. In eight cases there were additional possible contributing factors to dissection,these being reversible cerebral vasoconstriction syn- drome (2 cases), posterior reversible encephalopathy In conclusion, the first case of internal carotid artery dis- syndrome (2), pre-eclampsia, infection, Ehlers-Danhlos section following chiropractic treatment in a pregnant woman with SLE is described. Causality relating the Possible predisposing factors to arterial dissection chiropractic treatment to the craniocervical dissection in the peripartum period include intimal injury related cannot be established. The mother’s underlying medical to the Valsalva manoeuver during labour, alterations condition, her immunosuppressive treatment with pred- in arterial wall integrity due to pregnancy-related hor- nisone and the hormonal changes of pregnancy may all monal or vasoactive substances, increase in cardiac out- have contributed to vessel fragility, and her risk of cer- put and blood volume and the hypercoaguable state of vical artery dissection was increased in view of her his- tory of migraine. It is possible that the arterial dissection Three cases of craniocervical arterial dissection have had occurred prior to seeking treatment, and may have been reported in the setting of SLE or antiphospholipid become evident if the patient had sought the care of a syndrome, although one of these patients also had general practitioner rather than a chiropractor. Practi- Takayasu’s arteritis. In addition four cases of spontan- tioners should be aware of this possible complication of eous coronary artery dissection and twenty-one cases of neck manipulation in pregnancy and the postpartum aortic dissection have been described in individuals with period, particularly in mothers with underlying medical SLE. Hypertension, glucocorticoid use and dyslipidaemia disorders that may predispose to vessel fragility and may be factors in individuals with SLE that may lead to atherosclerosis weakening the arterial wall. Vascu-litis leading to chronic inflammation increasing vesselwall fragility has also been proposed as a contributing Written informed consent was obtained from the patient Migraine was shown to be associated with a two-fold for publication of this Case report. A copy of the written increase risk of cervical artery dissection in a recent consent is available for review by the Editor-in-Chief of Stuber et al recently published an critical review of the literature regarding adverse effects from spinal manipu- Competing interestsThe author declares that he has no competing interests.
lation in the pregnant and postpartum periods Theyidentified adverse events in five pregnant women, and two postpartum women. The four serious events AM cared for the patient, performed the literature review, and prepared the reported in the literature all occurred after cervical spine Morton Chiropractic & Manual Therapies 2012, 20:38 Received: 18 July 2012 Accepted: 23 November 2012Published: 19 December 2012 Lee VH, Brown RD Jr, Mandrekar JN, Mokri B: Incidence and outcome ofcervical artery dissection: a population- based study. Neurology 2003,67:1809–1812.
Maderia LM, Hoffman MK, Shlossman PA: Internal carotid artery dissectionas a cause of headache in the second trimester. Am J Obstet Gynecol2007, 196:e7–8.
Borelli P, Baldacci F, Nuti A, et al: Postpartum headache due tospontaneous cervical artery dissection. Headache 2011, 51:809–813.
Baffour FI, Kirchoff-Torres KF, Einstein FH, et al: Bilateral internal carotidartery dissection in the postpartum period. Obstet Gynecol 2012,119:489–492.
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Nisar MK, Mya T: Spontaneous coronary artery dissection in the contextof positive anticardiolipin antibodies and clinically undiagnosedsystemic lupus erythematosus. Lupus 2011, 20:1436–1438.
Rist PM, Diener HC, Kurth T, et al: Migraine, migraine aura and cervicalartery dissection: a systemic review and meta-analysis. Cephalalgia 2011,31:884–885.
Stuber KJ, Wynd S, Weis CA: Adverse events from spinal manipulation inthe pregnant and postpartum periods: a critical review of the literature.
Chiropr Man Therapies 2012, 20:8.
Cassidy JD, Bronfort G, Hartvigsen J: Should we abandon cervical spinemanipulation for mechanical neck pain? No. BMJ 2012, 344:e3680.
Wand BM, Heine PJ, O'Connell NE: Should we abandon cervical spinemanipulation for mechanical neck pain? Yes. BMJ 2012, 344:e3679.
Cassidy JD, Boyle E, Côté P, et al: Risk of vertebrobasilar stroke andchiropractic care: results of a population-based case-control andcase-crossover study. J Manipulative Physiol Ther 2009, 32:S201–S208.
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doi:10.1186/2045-709X-20-38Cite this article as: Morton: Internal carotid artery dissection followingchiropractic treatment in a pregnant woman with Systemic LupusErythematosus. Chiropractic & Manual Therapies 2012 20:38.
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