Cervical Artery Dissection, Thromboembolism and Stroke: A Lack of Chiropractic Causality
Written by: James Demetrious, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
No Causality
Current highly-powered research indicates no causal relationship between chiropractic care and Cervical Artery Dissection (CeAD).
Does Chiropractic Cause Thromboembolic Events and Stroke?
Post-manipulative mechanisms have been suggested as a cause of thromboembolism and stroke. These mechanisms are derived from case reports, temporal incidence, and speculation that are unsupported by high-quality research.
- Case reports offer weaknesses that include the inability to generalize results or to assess causality. [1] Journals, editorial boards, authors, expert witnesses, plaintiff attorneys, and patients should refrain from assigning causality based on information gleaned from case reports.
- Temporal incidence of CeAD is attributable to spontaneous events that may occur at any given time irrespective of activity.
- The evidence supporting a temporal relationship in the development and timing of a thromboembolic event associated with chiropractic spinal manipulation is unsupported by the preponderance of models in respective investigations.
What About Dissecting Pseudoaneurysms?
Dissecting pseudoaneurysms (dPSA) have been associated with CeADs and have been identified as a possible cause of thromboembolic events. Although the time window for developing dPSA varies across the patients, typically, dPSA develops over days to a few weeks and has been reported to occur in 17%–49% of patients with CeAD. [2]
In their large retrospective cohort, Mayo Clinic researchers Seven et al. recently published the following conclusion:
“In our large retrospective cohort, most extracranial dPSAs had a benign prognosis with medical therapy alone regardless of the artery involved (carotid or vertebral). These dPSAs do not rupture and increasing size on long‐term follow‐up is an uncommon event. [2]
Can We Protect At Risk Patients?
We are fortunate that CeAD and related strokes are extraordinarily rare events. However, awareness of predispositions to its occurrence may provide insight and allow for emergent medical care.
Heritable and acquired causes of CeAD are reported in the literature including connective tissue disorders and connective tissue degradation due to fluoroquinolone medications. [3]
Some pre-existing factors associated with thromboembolic events may provide clinical insight:
- Age > 50 years old;
- Heritable hyper-coagulopathy states such as Leiden V;
- Acquired hyper-coagulopathy states such as malignancy, diabetes mellitus, venous stasis, pregnancy, oral contraceptive use, lupus anticoagulant, postoperative state, immobilization, myeloproliferative disorders, and nephrotic syndrome;
- Hyperhomocysteinemia;
- Fibromuscular dysplasia;
- Arteriopathies;
- Patent foramen ovale;
- Cardiac arrhythmias;
- Chemotherapy;
- etc.
Interestingly, older patients do not appear to be at risk for CeAD. Whedon et al. recently reported:
“Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups. [4]
A Better Means to Identify and Protect At-Risk Patients
Too frequently, patients are unaware that they have medically recognized or unrecognized predispositions for CeAD, dPSA, thromboembolism, and ischemic stroke. Patients often do not disclose vital health history to chiropractors upon initial presentation, or on subsequent visits. Chiropractors often do not have access to medical records.
For these reasons:
- It would greatly benefit patients if physicians communicate predispositions of CeAD, dPSA, thromboembolism, and stroke with their patients and chiropractic colleagues.
- Patients must inform their chiropractors of these predispositions during clinical intake and new symptoms and signs on subsequent encounters.
An Impossible Diagnosis?
Despite best efforts utilizing current standards of care, it may be impossible to diagnose a CeAD or dPSA in the chiropractic office due to unreported and undisclosed conditions and medications, unidentified risk factors, transient symptoms, and asymptomatic presentations.
An onus of responsibility resides with medical providers and patients. Chiropractors must be privy to these medical predispositions. Improved communication can benefit patients.
References:
- Lowenfels et al. Grad Med Educ (2022) 14 (5): 529–532.
- Seven et al. Stroke: Vascular and Interventional Neuro. (2023) 3;3.
- Demetrious J. Chiropractic & Manual Therapies (2018) 26:22.
- Whedon et al. BMC Geriatrics (2022) 22:917.
The Role of PostGradDC
At PostGradDC we offer advanced CAD Certification.
PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is an internationally distinguished board-certified chiropractic orthopedist, educator, author, and editor. Register for coursework at PostGradDC.com.
Disclosure
The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment.
