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Show Occipital Infarction Following Chiropractic Cervical Manipulation .-\ -l-l-\I\H-llld 111,111 dl'\I'll1f'I'd ,1 l'lllllpkll' h"1l1l11l\'11111\" hl'I11I,1I111f'I,1 :: d,1\'~ ,11kI' 1IIldl'I't:"illt: l'hin'pl',1diC CI'I'\' ie,11 1ll,1I11f'lll,11I"Il. nH"Ill["Il'l11b"liSI11 Inll11 Ihl' \'l'rll'[' r"[',1"II,H ,'irClIl,11I"I1-,1S till' C"I1~l'qlll'l1el' "f Ir,HUll,1 tll thl' \'l'rtl'h',ll ,Hkril'~ b\' ,ldj,lCl'111 b"Ill'~, 11111~c1l's, alld 1i~,lllll'llb ,illrll1~ l\\i~t'l1t: ,111.1 l',kl1sil'll11f thl' l1l'd,-is thl' prl'[',l['k Illl'Ch,llli~111 f,lJ' ,'ccipit,ll illf.ndillil ,111.1 "111\'1' "Ir,'!.-"" III Ihi~ ,111.1 prl'\'i"ll~ C,bl'~. Uthl'1' (ll'III"'" f'hll1.lIIllIC 1ll,1I111t'~I,ltl"Il~ I'q'lll'kd illdlldl' Illlrnl'r'~ ;\'ndrl'll1\' ,111.1 ;I,th 11\'[\'l' ,1I1d t:.l/l' p,lbil'S. From tht: Dq'drtml'nh ot "urgl'rl' II )"""011 01 l If'hth,d' mologv) and Nl'urology, Unil','r~i1\' ot M,''',ldH''l'lh Ivkdi...d Schuol, Wurct:SlL'r, Ma~~achll~,'ll~. Addrt:~s corrl'spondence ,1Ilel reprilll rl'qu,'~h 10 /Jr. I. IV Gittinger, Jr., at Univl'C'ity ot M,l",Il'hll'l'II~ M,'di,',d Cl'llkl', 55 Lake Avenul' North, WorCl'~tl'r, Mi\ II/hilS, U..... A. /I Occipital infarction'> in per...lln ... under the age uf 50 vear... Il'ho have nu knllwn artt.'riusclerutic \'ascul~ r disease are reported tu result from emboli (1), frum severe head trauma and other causes of cert'braledem,l (2,3), and as a cumplicatiun uf migr, line (.f), ","stemic lupus en'thematosus (S), and h\'putension (h), Occipitcll infarction iollo\\'ing cervical m,1I1ipul,ltiun is rare (7). The case reported 11t're sen't'S tll emphasize the features ui strokes apparenth' caused b\' in,llhertent injun' tll the vertebral arteries, CASE REPORT A .f.f-vear-old man Cl1l1Sldted a chirt1practl1r becaUSt' ui a pressure sens,ltiun in the back ui his neck that had been prt'sent fllr ,1bllut 1 \\'eek. He had t\\'o sessillllS lli manipulation oi his neck. Two deli'S laler, he ,1\\'l)ke and was unable tll see to his right. He denied tacial pain but repl1rted a sensatilm ui numbness in his It'lt hand. He sa\\' lights clnd lint'S in his blind field that he dL'scribed as psvCIwdelic. On e'\,lminatillll his \'iSU,ll ,lCuit\, 1\',15 201:; in bLlth l'Ves, C~lldlll,lI1ll ViSU,ll tields rL'I't"lled ,1 Cl1lllpick right hLlIl1ll11\'1l1ll1lS ht'lllialll1pi,l splitting fi'\dtiLln, Optllkilletic IwSt,lglllUS \L1S present S\'Illnwtricdlh', His llphth,llll111lllgic,ll ,11ld neUrl)Llphthdlnh) lllgic,ll t''\,llllin,lti~)nS \\'ere l)ther\\'ise unrelllark,lblt', A llt'Ufl)lllgy cOllsulte1nt found a relative Idt hvperrdll"\i,l, Thl' p,ltient \\',10., hllspit,lIiZt'd, Cl1mputed tl)ml)grdphv dl'lllunstr,lkd ,1 I,Hge Idt l1c,"ipit.1l iniMctilln (Fig, I), R,ldiugr'lphs llf the cen'ic,ll spine shl1wed Llnly mild degelwr,lti\'l' ch,1I1ges, The results L)f blLlLld stlldi~'s, indudillg serulll chl)lestewl, were nLlrm,l!, l''\cept fLlr ,1 pl1siti\'t' ,1I1tinudear antibod~' test result, which, lIn repedt, was 2 + homogeIWLlUS with ,1 pattern of I'Hge speckles that was cl1llsidered nonspeciiic. The test illr anti-extract,1bit' IlUdl',lr dlltigl'n WdS negdtive, I:! I W Clrl/NeLl\, 11\. FIG. 1. Adjacent 10-mm aXial slices showing a low-density area In the left occipital lobe (arrows), compatible with infarction Cardiac ultrasound showed no e\'idencL' oi mitral prolapse, ur leit ventricular or right atrial cll)t. A digital subtractiun angiugram oi the carotid arteries was nurmal. The patient was placed un a regimen of aspirin; results ui the iollow-up examination were unchanged. DISCUSSION There are numerous repurts oi strokes tolk1\\'ing cervical manipulatiun, although stwkes appclrently occur in only a small pwportion oi patients who receive such treatment (7-11). The same clinical picture may develop aiter cen'ic,ll trauma (12) or exercise involving hyperextension oi the l1L'ck (13), The pwbable mechansim is mechanical compression 0 f the a rteries by ,1 eli ace n t bo n L'S, muscles, and Iig'lIlwnts. Closure 01 tlwse \'L'ssl'ls with neck wtation is seen angiogr,lphic,11h' (1-1, I:;), and angiugrams and autopsies ot ,1fteded p,ltients have demonstrated thrombosis in tlw \'L'rtebrobasilar circulation (7). Most such stwkes have il1\'olvL'd the brainskm and cerebt'llum, in a iew inst,llKes c,lusing de,lth. Neuro-oph tha Imological ma ni festa tions incl ude Horner's syndwnw (both in isol,ltion and ,1S p,nt of a lateral mL'dullary syndwn1l' (r;,LJ, 11)). internuclear ophthalnlllplegia (9,10), pdralYsis ot conJugate gaze (lh), the loch'd-in syndwn1l' (~, 17), ,md bilateral sixth nerye palsy (9,17), Occipital iniarction may be the result of emboli-zatlon twm the prImar\' sIte elf inJun'. Brain (18) repurted the case llt a hS-\'ear-llld \\"lmwn treated with diatherm\' and neck tractlL1n fur cervical spund\'k)sis \\'I~o then de\eloped a leit homon\' mous hemial1llpia. Obstructiun oi the right poskril) r cerebral arkn' \\as pl)stulated. Sherman et al. (LJ) described the ca"e l)f a 39-\'ear-old woman \\'hl) developL'd blurred \ision and oscillopsia during a chlwpractic Iwck manipulatilm, Examinatil1ll I \\'eek lakr rL'\ealed a right "uperior quadrantaIlL) p"l,l Computed tlm1llpaphy showed a left l)ccipiL1l IUCL'n\', ,md angiopaplw demonstrakd occlusil1ll llf the left pl)"teril)r cerebral arkrY. r...nlegL'r ,1nd Okazaki (;-) cl)ntributed two e,lSL'S tl) tlw likr,lturL'. LIne \\'.1" l)i a 39-Year-old \\'om,1I1 \\'hll \\'ent mtl) a Cl)ma after chiropractic manipulatil1ll ttlr headache; there were multiple cerebral infarcts lln cl)mputed tomography, The patient was left \\'ith a bilateral homonymous ht'mi,lI111pi,l. In tlw lltlwr case, a 53-year-old man bl'canw "l)mnl)!t'nt ,1nd Clmiu"ed iollowing chiropr, lctic manipul,ltil1ll ,md had a dense bilateral superil) r 11l'mianop"ia, In thi" patient. both posterior cerebral MlL'riL'" \\'L'rt' ob"tructed angiographically, As in prL'vious repl)rt", the patient presented hnL' \\\lS reI.1tiH'h· young, had no evidence oi atht'rosc! t'wsi" l)r other \'a"cular abnormalities, and developed a neuwlogical deficit some hours after the manipulation. Walsh and Hoyt (19) suggested that the delayed effect of such manipulation "may be related to intimal injury, mural thrombosis, and embuli"m while the imm~diate effects are best ex- /3 plained by vascular cl1mpressilln ,1Ild redudipll ill blood flow," Another ppssibk nll'l'h,1I1ism is I'l',ll'tive vasospasm similar III th.ll ppslul,lll'd ill migraine (7), The appwpriale man,l~t'n1\'nl III Ihis l'nlit" is uncertain, Robertson (20) SU~~l'sled Ih,ll p,lliellls with on'" ischemic s"mplpllls 11r l'\'idl'IlCl' III ,1 small, nonpwgressive br,lillsll'm stwl..e be Irl',lled with anticoagul.lnts III PI'l'\'l'lll pl'l1~ressipn, I k pwpl'sed immedialt' sUr~i(,ll Illl'r,lp" in ,1 prll~ ressin~ stwl..t' s\'ndwllll', HI' ,liSll rel'lllllnll'ndl'd the use llf H'rtebr,11 ,1Il~illgr,lpll\', ,1 slud" Ih,lt W,lS not dlme in the prl'sent (.lSI' bl'c,Hlst' till' rl'sults \\'lluld not haH' changt'd tl1\' 1ll,1Ilagenwnl pi Ihl' patient and because there is ,) risk involvl'd in the procedure (21), Digital subtractilln angiography 01 the carotid arteries was perlormed to exclude an anomalous vertebral circulation (22). which might have changed the therap", Chiropractors are aware l11 Ihese occurrences (23), which are probab'" mllre common than Ihe number actualh' reported indicates, Patients presenting with homon"mous hemianopia should be asked whether the" ha\'e undergone recent chiropractic manipulations, There remains the question 01 whether the putati\'e benefits 01 cer\' ica] manipulation justify the risks, REFERENCES Jackson, A C, Bl,ughner, D, R, Jnd BJrnt'tt, II) M, ~litral \'ah'e pn'!ap'e and cerd:>ral i'chemic t'\Tnh in \'oung patIt'nh ,\'t'lIr"ll)~u 3-1: iH~-iHi, I%~ , Trobe, ) D, Lorber, ~I L, and 5chlt'zinger, \: 5, boIated homol1\'muu' hemianopia: J reVlt'\\' ul l(q ca,,', ,';rdr, O,.ht/r,I/;",'/ 89: 3i7_lHI. I'lI3 3. Drummond, J \\', Hall. D I., and Steen, W H, Ir BII,lt-eral homol1\'mou, hemlan"pla \\'Jlh hvp"naln'ml,l 1\"" Ophthu/IIl,'1 12: KiS-HiH, l'lHII, -I, Doriman, L J, \lar,hall. W H, ,Ind En/m,lIln, [) " It'rebral miarctlOn and migr,lInt': clinical .1I1d radll,l"gll- n'rrelations, ,\'t'lIr"I"XlI 29: 3Ji - 3~~, 14i4 5 Trabnulsl, E, I., \lan,our, A :\1.. A',,'ad, 1\1 I , Cholrzuddin, W" and Fra\'ha, R, A.. Hom"nvm"u, Iwnll,lI1"pi" ,Ind 'V'kllll' lup'" l'rvllll'm,II",u'. f. eill/, NI'I,ru-"I'II111,,/,",, 1. 5: h 1 hh, IlJH'; h, ~lr,J11d,.;a",d, ~" i\nd,'r,,'n, (, c, .. Ahl,.;rl't'n, I' , ,lI1d Ni,'I,,'n, I', L, VI~uoll di,lurh,l/lll" 1"llllwln,.; ,1l'Ull', Ir,1I1, i"111 hYI',>!,'n,,,,n in "\'f",rl.'n'i\'" p,lIi.'nh, I\Ila Ak" ,,,,,",, 216: ~17 ~~~, I'}H~, i ~nll·hl'r. B. 1\., dnd ()I-..d/.I"I, II Vl'rtl'br.l!-b(hildr dl,trihu( itlll inJ.HltlllJ'l Itilltlwing ,i'llfl'pr.ulll ll'n"j(.ll nldnlpuld~ /1(111, ,\1'"1" t'l/ll I',.", 55: 1~~ 11~, 14xo, H, ~.'I\('llh,I" I' I'" L"ld",\\', I~, I" Wl'ndlon,.;, I., I~" <lnd (;,,1,1. I II 1\' Vl'r1,'br(lh","", IIlI"rit" I"I/"\Yln,.; It'n'I(,11 m,llllplll,t1i"n I/\M/\ 244: I~='O J~='1. 14HII 'i, ~1\('"n,lI1, 11, C, 11",\, 1<, t. , ,Ind 1.,I,t"n, ) I), Abrllpl ,:htlllgt.· .... in Ill'<llf pu.... itil1n dllllu'rt'brtlllnl.HdllJn. '-l!rn/.;I' 12: ~--h, I'IHI iii ~ll11n)(ln', " ( , c,,,,,, y c" W,""l'r, (, , ,lIld fldrl'l'\', J' Tr,ll1l11<1 I" 111<' \'l'rtl'hroll arl"rI' r.,I,IIl'd I" nl"'" manlpulali( lll '\1.''', I :\11,1 1: !Hi-IHH, J'IH~ J 1. Hr.llln, J ~. Brain .... ll·1l1 Inl.Hdltlll dUl' III thlrllrlrdl til md-nipul, ltllln "f tht' (l''''lloll 'pin., S,,"t1r \Jr'" I 76: ] ~117-] ~lII, I 'JH1 I~ Ll'\'\', l~ L, Dugan, I \1, Ill-mdl, I L, olnd I'.·"llI1g, I L<lt~'ral medullar\' .... \'ndr(lllll' dttl..'r nvc"- Injun" .\'1'lIfO!II:,tf 30: 7HH-i411, 14HII ' 13, N,lgll'r, IY \'t'rtt-br,ll arln\' "l',lrllell"n b\' h\Tt'rl',lt'n""n lli Ihl' IW""-: rep.'r\ (II Ihrn' ,',I't" :\/, h ('IIII' ,\ 1.',1 /~,'II"/'I/ 54: ~3i -2~1I, 1471 I~, Barll'n, I. \Y" and \lar,.;"I", \1 T R"lall"nal "b,lrllC!I(ln tli Iht' \'t'rll'bral arll'n' al IIw allanl(la,lal )PII1!' ,\'1'/""'-",1,I> ft','i119: 117-1~(), 1'I7=" ]:i, Yang, r, L, Latack. ) T, C"bnt,l,t'n. T l), I'na"t', I 1::, Gt'bars"i, S S, and Chandkr, W-r' Rlllalll'nal \'erlt'bra! artt'rv "celu,i"n al CI-C2, ,'\ 1..\' I~ 6: 'IS-lilli, !4H;, In, Par";n, r, J" \\'alli,. \\' E.. ,lIld \\',j,,,n, I L \ t'rlt'hal Jrler\' I'celll'l"n t"I/""'IJl,~ m,lI1'f'ul,lll,ln ,'I lilt' nt"I--. ,\ L .\1.',1, I, 88: HI-~~l, j47S Ii, Lvnl''''~' ~,,1I1d \\',l~I11,1I1,.--\, [l :\l'uH11"h'CJI dt'l,cIII"I· 1';\\'ln,.; Ct'I\'IC,ll m'ln;pul,ltl"n, .~/IlX ,\'<''''''/ 2: 12 J-12~, 197~ 11'\, BrJlI1, D, M.. S"m<' un",l\'t'd pr"hlt'm' ,'I ct'I\')(,,1 'f"lI1d\'I"" i~, R,. ,"It'd 1,1: 7il-777, 1%3 19, Wabh, F, B.. and H,,\'!. IV F' ellllll',I! \'I'"r"-"l'hthol!lIIl>/I',~" (3rd t'd) William & \\'II"IJl', BaltJnwrt', !LJt>LI. p lH~1 20, R(lbt'rt,,,n, I T :\t'c" m.1n'f'ulall,'n ,1" J e,llI"e l,t ,Ir,'''e Stn,kt'12: I. ]41'\1 ~l. Wi"hMt, D, L, Cl>mplicatIl1n, 111 \'t'rkhal Jnhll'hr,lf,l1\ .1' (,'mf'Mt'd t" n"n-\'t'rkbr,ll ct'rt'h.ll ,1n,hll'hrJf'!1\ In ~r' "Iudll''', Alii I Rl'<,'IIX"III,I, 1\".111/1" TiJ,-,. \'"c/ ,\kd 113: S~i-;.li, 14il " Bt'mMdl, L" ,lnd Ddt"". I' "~''''hll'P,lf'hl'' 'Iud\ ,It ,I r.Ht' ~lntlm,llpu ... lIf1gin pt thl' \"l'rkbr.ll .Hkr\' .\"('/lIt11.rdI111t1\'ll Q: ~.l-~i, l'Ii; , , ~3, Terrd!. A C, I, ,llld \\'t'bb, ~I:\ \t'rkl'r"b,l',j.H ,leCIdt'nl" (\'A) 1"l/tl\\'In~ ,'<,n'lt',,1 'f'1I1t' ,ld\u"lnWnl m.lIllpul.ltilUl. }. A",. l-hirll/'rlldh" :\""l)l 12: 24-~7. IlJ~~ I ellll NI'''"'-I'I'itlitllll1lo1, Vol. 6, No, 1. 1986 |
