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Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association
Study Questions:
What is the current state of evidence on the diagnosis and management of cervical artery dissections (CDs) and their statistical association with cervical manipulative therapy (CMT)?
Methods:
Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.
Results:
Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery–artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of pre-existing CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but they suggest that no single test should be seen as the gold standard.
Conclusions:
The authors concluded that CDs are an important cause of ischemic stroke in young and middle-aged patients.
Perspective:
This scientific statement reviews the current state of evidence on the diagnosis and management of CDs. They are an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs, and most population-controlled studies have found an association between CMT and vertebral artery dissection stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine. For patients with transient ischemic attack or ischemic stroke resulting from CD, antiplatelets or anticoagulant therapy for 3-6 months is reasonable. Endovascular therapy may be considered for patients with CD who experience definite recurrent cerebral ischemic events while on appropriate antithrombotic therapy.
Keywords: Stroke, Cranial Nerve Diseases, Follow-Up Studies, Ischemic Attack, Transient, Fibrinolytic Agents, Brain Ischemia, Headache, Carotid Artery, Internal, Vertebral Artery Dissection, Public Health, Expert Testimony, Neuroimaging, Thrombosis, Embolism, Magnetic Resonance Angiography, Physical Examination
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