Korean J Neurotrauma.  2018 Oct;14(2):159-163. 10.13004/kjnt.2018.14.2.159.

A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation

• Jeong DK
• Hwang SK

• KMID: 2424332
• DOI: http://doi.org/10.13004/kjnt.2018.14.2.159

Abstract

We describe the case of a patient who had infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks ago, he was treated by a chiropractor for intermittent neck pain. 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. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. He was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae. 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.

Keyword

Cerebral infarction; Dissection; Lateral medullary syndrome; Manipulation, chiropractic; Vertebral artery

MeSH Terms

Adult
Angiography
Arteries*
Brain
Cerebellar Diseases
Cerebral Infarction
Chiropractic*
Emergency Service, Hospital
Humans
Infarction*
Lateral Medullary Syndrome
Magnetic Resonance Imaging
Manipulation, Chiropractic*
Manipulation, Spinal
Neck Pain
Pica
Vertebral Artery
Vertigo

Figure

• 

  FIGURE 1 (A) Radiologic images at admission. Initial brain computed tomography does not show the abnormal density in the cerebellum. (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. (D) Gradient-echo image of the brain MR imaging suggests the blood clot in the PICA (black arrow). (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). RCCA: right common carotid artery, RVA: right vertebral artery, LCCA: left common carotid artery.

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  FIGURE 2 Transfemoral cerebral angiography. (A) Left vertebral artery (VA) angiography shows an occlusion of VA at extracranial portion near the transverse foramen of C6 (arrow head). (B) Right VA angiography shows a retrograde blood flow to the left VA and the occlusion of left posterior cerebellar artery (arrow head).

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  FIGURE 3 Computed tomography (CT) and CT angiography after 1 month. (A) Brain CT shows the changes for the chronic phase of the cerebellar infarction in the posterior cerebellar artery territory. (B) Three-dimensional CT angiography reveals recanalization of the dissected vertebral artery (arrow head). (C) CT angiography suggests a suspicious dissected wall of left vertebral artery (arrow head). RCCA: right common carotid artery, RVA: right vertebral artery, LCCA: left common carotid artery.

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  FIGURE 4 Computed tomography (CT) and CT angiography after 3 months. (A) Brain CT shows the low density in left posterior cerebellar artery territory. (B) CT angiography shows improvement of the dissection of the left vertebral artery, but still remaining of focal stenosis. RCCA: right common carotid artery, RVA: right vertebral artery, LCCA: left common carotid artery.

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