Thursday, April 12, 2007

Just a Quick Tug

Here's another interesting case straight from the "classic" board questions series (that actually occur in real life)...

CC: H/A and speech change
HPI: 27 yo F presents w/ a headache and speech change. She had gone to her chiropractor earlier in the morning to get "adjusted". She felt fine afterwards and went home. Later she was at her OB's office when she began to have a H/A. After the appointment she went home and noticed that she had some aphasia and right-sided vision loss. All symptoms have since resolved and denies any current neuro deficits.
PMHx: Denies
Meds: Lexapro, HCTZ
SHx: Denies
PSHx: Denies

V/S: BP: 127/81 HR: 70 RR: 20 Temp: 98.3 Sats: 98% (RA)
PE: (Pertinent findings)
A&Ox4; Visual fields intact; No focal neuro defictis. Unremarkable exam

Initial Diagnositc Testing: Basic labs and beta HCG were negative. CT head was also negative.

Based on this history and symptoms, what would be of primary concern and what would you order?

A CT angiogram of the head and neck were ordered to r/o carotid artery. The patient did end up having a dissection of the proximal left ICA. She had patent intracranial vessels and intact posterior circulation. She was transferred to St. Joe's neurosurgical service for evaluation.

Although uncommon, cerebral artery dissection is an known adverse outcome of chiropractic manipulation. It can also occur spontaneously, after whiplash, neck-stretching, and in certain connective-tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome, etc). It most commonly occurs in the extracranial carotid artery between C2 and the base of the skull.
Symptoms may include transient retinal ischemia, cerebral infarct, face and/or neck pain, Horner's syndrome, audible bruits and a pulsatile tinnitus.
Diagnostic imaging includes CTA or MRA to r/o dissection. Remember that CTA has a 1% complication risk.
Treatment includes neurosurgical evaluation. Heparin will sometimes be started to prevent thrombemboli, but I'd discuss it w/ your consultant before starting treatment.
So go out there and crack those necks...


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