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Journal of Manipulative and Physiological Therapeutics
Volume 24 • Number 8 • October 2001
0161-4754/2001/$35.00 + 0 76/1/118204 © 2001 JMPT

CASE REPORTS
Cervical Manipulation to a Patient With a History of Traumatically Induced Dissection of the
Internal Carotid Artery: A Case Report and Review of the Literature on Recurrent Dissections
Sidney M. Rubinstein, DC,a and Scott Haldeman, DC, MD, PhDb

ABSTRACT
Objective: To describe the use of rotational cervical manipulation in treating a patient who had
undergone a traumatically induced dissection of
the internal carotid artery and to review the literature on recurrent cervical artery dissections.
Clinical Features: A 21-year-old woman with
hemiparesis from an internal carotid artery dissection that occurred as the result of a motor vehicle accident had neck pain and headaches. Moderate
range of motion restrictions in the neck were present along
with articular restrictions to movement palpation.
Intervention and Outcome: After a year of soft-tissue treatment, we obtained detailed, informed consent from the patient
to attempt diversified manipulation to the neck. The patient
described greater and more immediate relief and longer pain-

INTRODUCTION
Cervical artery dissection (CAD) involving the vertebral
and carotid arteries may follow cervical spine trauma,1-3 be
spontaneous without obvious precipitating activity,4-6 be the
result of minor or trivial trauma associated with normal
daily activities,4,7,8 or follow cervical manipulation.9-11 It is
difficult to explain why vertebral artery dissections occur in
only 1 case per 1 to 3 million cervical manipulations12 and
why they are rarely reported in the whiplash literature.
Although more common than vertebral artery dissection in
the general population, CAD is rarely associated with cervical spine manipulation and has only 5 documented cases in
the literature.13-17 If the primary factor involved in the dissection process was trauma associated with neck movements
that stretch the vertebral and carotid arteries, one would
expect a much greater number of cases.

a

Private practice of Chiropractic, Soest, The Netherlands.
Department of Neurology, University of California, Irvine, Calif.
This paper was presented at and received the private practice
award from the World Federation of Chiropractic 6th Biennial
Congress, Paris, France, May 24-26, 2001.
Submit reprint requests to: S. M. Rubinstein, Praktijk voor
Chiropractie, le Heezerlaantje 2, 3766 LW Soest, The Netherlands
(e-mail: chiro@rubinstein.demon.nl or HaldemanMD@aol.com).
Paper submitted August 11, 2000.
b

doi:10.1067/mmt.2001.118204

free periods than could be achieved by softtissue treatment alone.
Conclusion: Patients with previous cervical
artery dissections may present with unrelated neck pain and headaches and request
treatment. In selected cases, with complete
informed consent, manipulation of the neck
may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the
second dissection. Care must be taken in extrapolating
the results from this case to any other patient with a history
of cervical artery dissection. (J Manipulative Physiol Ther 2001;
24:520-5)
Key Indexing Terms: Manipulation; Carotid Artery; Complications; Dissection; Cervical Artery Dissection; Vertebral Artery

The association of these dissections with disorders such
as fibromuscular dysplasia, Ehlers-Danlos syndrome types
IV and VI, and Marfan’s syndrome,4 and the random nature
of these events has led to the increasingly accepted theory
that there is an underlying genetic arteriopathy in the cellular matrix of the arterial connective tissue that predisposes
certain individuals to CAD.18-20
Assuming that CADs are due to an underlying arteriopathy, one might expect that a previous arterial dissection
would markedly increase the risk of a second dissection,
particularly if there was further trauma. Furthermore, it
would also be expected that a history of arterial dissection
would be a contraindication for cervical manipulation and
should alert a patient to be very careful to avoid traumatic
neck movements of any kind.
A patient with a history of a post-traumatic carotid
artery dissection following a motor vehicle accident
recently sought care from one of us (SR), and requested
cervical manipulation. The patient, who had benefited
from cervical manipulation before her dissection,
wished to have further manipulation despite being
informed of the potential risks of a recurrent stroke.
This precipitated a search of the literature to determine
the risk of recurrent dissection in the cervical arteries,
and also to determine whether there had been any
reported cases of postmanipulation dissections in
patients who had previously been diagnosed as having a
dissection in any location.

Journal of Manipulative and Physiological Therapeutics
Volume 24 • Number 8 • October 2001
Manipulation and Recurrent Arterial Dissection • Rubinstein and Haldeman

Table 1. All studies of recurrent dissection identified from the literature
Number of recurrences
Reference
Case series
Schievink et al25
Leys et al21
Bassetti et al22
Bogousslavsky et al23
Pozzatti et al24
Case reports
d’ Anglejan Chatillon et al28
Goldstein et al29
Youl et al26
Rohr et al27
Grau et al31
Grond-Ginsbach et al30
Total

N*

Previously
undissected artery

Previously
dissected artery

Total number of
recurrences
(% of N)

Mean follow-up
(mo)

200
105
74
30
19

16
0
2
0
0

0
4
1
1
0

16 (8)
4 (4)
3 (4)
1 (3)
0 (0)†

89
36
34
38
98

1
1

1
1
1
1
3‡
2‡
33

1
1
1

1

*Population sample.
†Two patients had recurrent symptoms without verification of a second dissection on echo- or angiography.
‡No detailed data were provided on these additional cases.

CASE REPORT
A 21-year-old woman had a serious auto accident in
August 1995 that resulted in considerable head and body
trauma, including rib, femur, and mandibular fractures.
There were no fractures to the spine or pelvis. As a result of
a dissection to the right internal carotid artery (ICA), the
patient had a stroke. The diagnosis was confirmed on computed tomographic angiography and Doppler ultrasonography, which revealed damage to the ICA at the bifurcation of
the carotid artery, extending superiorly. This resulted in a
large infarct in the distribution of the anterior and middle
cerebral artery. Neurologic examination shortly after the
accident revealed hemiparesis, hyperreflexia, and hypertonicity of the left arm and leg. In addition, she was dysphasic and had a slight facial palsy. After 6 weeks, the patient
was transferred from the acute care hospital to a rehabilitation center, where she was confined for a number of months.
Nine months after the accident, the patient sought chiropractic care for residual headaches and pain in her neck and
lower back. Before the accident, she had successfully received chiropractic manipulative therapy for the relief of similar symptoms. At the time of presentation she was confined
to a wheelchair and moved with great difficulty. Clinical
examination revealed residual spastic hemiparesis and facial
weakness, moderate to severe decrease in cervical range of
motion, moderate to severe articular end-feel restrictions, and
extreme hypertonicity of the neck and shoulder girdle muscles. We initially decided to limit treatment to soft-tissue massage and gentle mobilization of the neck and back. This provided her with some relief of her symptoms. This relief,
however, was of short duration, lasting from a few days to 1
week. In the ensuing year, the treatment plan was changed
very little and was interrupted by various surgical procedures
to correct other residual symptoms from the accident. Her
neurologic rehabilitation continued, and she gradually became less dependent on her wheelchair and was able to take
short walks (± 10 m) under her own power. However, she

continued to complain of recurrent headaches, and motion
palpation of the neck revealed segmental blocking in the
upper and lower cervical spine that could not be resolved with
massage and mobilization.
The patient requested the type of cervical manipulation
treatments she had received before the accident. We explained to her that manipulation to the neck might or might
not provide more lasting relief of her neck pain and
headaches. The patient was also informed of the potential
for a recurrent stroke, of our lack of knowledge of the risks
involved, and of the probability that her degree of risk after
manipulation was likely to be higher than the general population. She was then asked to give a formal consent before the
treatment. We explained a second time that it was a potentially risky maneuver and could result in exacerbation of her
present symptoms or a second stroke. The patient felt that, in
her situation, the benefits outweighed the potential risks.
Two years after her accident, and approximately 1 year
after she had begun chiropractic treatment, manipulation of
the cervical spine was added to the treatment regimen. The
patient has since received more than 30 standard diversified
cervical manipulations over a period of 27 months to both
the upper and lower cervical regions. These were performed
with the patient supine and with contacts taken at the articular pillars. A high-velocity, low-amplitude manipulative
thrust was given from posterior to anterior with sufficient
rotation to cause joint locking before the thrust.
Outcomes were assessed using the verbal rating scale
(VRS). The VRS is an 11-point verbal scale, with “0” representing no pain and “10” representing unbearable pain. The
degree of pain was assessed before the treatment and again
within a few minutes after the treatment. Treatment with
mobilization and massage alone typically resulted in only a 2point change on the VRS (usually from a value of 6 to a value
of 4). However, when manipulation was added, the change in
VRS was typically 4 points (commonly from a value of 6 to a
value of 2). Of greater significance was the patient’s report

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Manipulation and Recurrent Arterial Dissection • Rubinstein and Haldeman

Table 2. Percentage of multi-vessel dissections by initial
presentation and by recurrent dissection
Percent multi-vessel dissection (N) by:
Reference
25

Schievink et al
Bassetti et al22
Leys et al21
Bogousslavsky et al23

Initial presentation

Recurrent dissection

28% (56/200)
11% (7/81)
5% (5/105)
3% (1/30)

6% (1/16)
0% (0/3)
0% (0/4)
0% (0/1)

that the manipulations provided relief for many weeks, compared with the few days experienced in the beginning of the
treatment period. The patient continues to request treatment
approximately once per month, and spinal manipulation is the
only treatment modality that provides her with immediate and
relatively long-term relief of her neck pain and headaches.
Four years after her accident, the patient has also made considerable progress in her neurologic function and is no longer
dependent on her wheelchair.

DISCUSSION
Case reports and case series were identified by using an
on-line search of MEDLINE for the years 1966-1999 with
these key words: (recurrent) carotid artery dissection;
(recurrent) vertebral artery dissection; (recurrent) cervical
artery dissection. Cross-tabulation was performed from the
reference section of all articles on the topic and included
articles in both English and French.
We identified 3 prospective studies21-23 and 2 retrospective studies24,25 that presented long-term follow-up of
patients who had had CADs. One study21 included all cases
of dissection, including those resulting from trivial or major
trauma, whereas the other studies reported only on those
with initial spontaneous dissections. There were an additional 6 papers in which a total of 9 case reports of recurrent
dissections were presented.26-31 This search resulted in a
total of 33 cases of recurrent CADs identified in the literature (summarized in Table 1).
Frequency of recurrences. The 5 sequential case series21-25 followed a total of 428 patients with an initial CAD. The average length of time for the follow-up in these case series was
approximately 5 years. The risk for recurrent dissection
reported in these articles varied from 0%24 to 8%25 over the
period of follow-up, with a median of 4% (Table 1). Leys et
al,21 however, believes that the study from Pozzati et al24
may not be representative because they report a higher rate of
mortality and disability resulting in a lower rate of recurrence. Despite this, Pozzati et al do report recurrent symptoms in 2 patients without verification of a second dissection.
By dividing the number of follow-up months by the total
number of recurrences, the likelihood of a second dissection
in patients with a previous dissection appears to be in the
region of 1% per year with a cumulative risk of 9.5%21 to
11.9%25 for the 10 years after the initial dissection.
Arteries of recurrence. Recurrent dissections may occur in a
previously dissected or undissected artery. The largest study,
by Schievink et al,25 which also had the greatest number of
recurrences, did not describe any case where the recurrent dis-

section was in a previously dissected artery. However, recurrent dissections in previously dissected arteries are reported in
the other articles (see Table 1). On examination of all case
series and case reports (admittedly skewed by the one study),
the second dissections seemed to preferentially affect a previously undissected artery (70% of the known cases).
The initial and recurrent dissections, furthermore, need
not be in one of the cervical arteries. There are 2 case reports
in which a dissection occurred in a renal artery after initial
CADs (the initial dissections involved bilateral vertebral
artery and ICAs in one case,25 and bilateral ICAs in the
other).32 There are also reports of 2 cases of aortic artery
dissection many years after an initial ICA dissection.33
Bilateral dissections. Multiple artery dissections are not an
uncommon initial presentation of CAD.32,34 In 4 of the 5
case series mentioned, for which data is available, 3% to
28% of patients (mean 12%) initially presented with multiple CADs (Table 2). However, among those with a recurrent
dissection, only 1 case resulted in multi-vessel involvement.
This case presented with bilateral dissection of the ICA after
an initial bilateral dissection of the vertebral artery (VA) 7
years earlier.25
Precipitating factors in recurrent dissections. The issue of recurrent dissection in a previously dissected artery is of particular concern when considering manipulation or the risks of
trauma for patients who have experienced 1 episode of arterial dissection. A more detailed analysis of the 9 cases in
which the second dissection occurred in a previously dissected artery revealed that 7 dissections were at the level of
the previous dissection (Table 3). In the 4 cases in which a
detailed medical history was given, connective tissue disease (eg, fibromuscular dysplasia or Ehlers-Danlos disease)
was cited as a predisposing factor. In a fifth case, migraine
was considered a potential predisposing factor.4 In 2 of 3
cases where the initial dissection was spontaneous, the subsequent dissection was also spontaneous. In all of these
cases but one, the recurrence occurred many months after
the initial dissection.
Risk factors for recurrent dissections. Only 1 study had sufficient numbers of recurrences25,35 to be able to identify possible risk factors. The risk factors identified were young age
(<45 years) and a family history of arterial dissection. For
those younger than 45 years, the cumulative rate of recurrence was identified as 16.8% during the 10 years after the
initial dissection. This is much greater than the recurrence
rate noted in those patients older than 45 years (6.1%). In
those patients with a family history of arterial dissection the
rate of recurrence was 50% (n = 5/10), compared with 5.8%
(n = 11/190) for those with no family history. Factors that
were shown not to have a relationship with recurrent dissection were sex, site of dissection (there was an equal predilection for those with prior VA or ICA dissection), multiartery dissection, hypertension, smoking, or the use of oral
contraceptives.
Trauma and manipulation. In only 2 cases in which a recurrence was described was there any mention of spinal manipulation as a contributing factor. One case involved a patient

Journal of Manipulative and Physiological Therapeutics
Volume 24 • Number 8 • October 2001
Manipulation and Recurrent Arterial Dissection • Rubinstein and Haldeman

Table 3. Reported cases of recurrent cervical artery dissection in a previously dissected artery
Cause of dissection

Sex,
age (y)

Artery
involved

First dissection

Second dissection

Possible predisposing
factor(s)

Time elapsed
between dissections

ND
F, ND

Carotid
Carotid

ND
ND

ND
ND

ND
ND

32 months
14 years

F, 33

Carotid

S (asymptomatic)

S

F, 41
F, 28
M, 13
F, 47

Carotid
Carotid
Vertebral
Carotid

S
Chiropractic maneuver
Judo
S

S
S
S
While awakening
from general
anesthesia

FMD + habit of smoking
+ contraceptive use
EDS
EDS
FMD
Migraine; no other
history given

Possibly 10
years
4 months
24 months
10 months
3 years

Reference
Bogousslavsky et al23
d’Anglejean28
Chatillon et al28
Goldstein et al29
Leys et al21
Leys et al21
Leys et al21
Bassetti et al22

ND, No data; S, spontaneous; FMD, fibromuscular dysplasia; EDS, Ehlers-Danlos syndrome.

whose original dissection followed cervical manipulation
and who had a second spontaneous dissection 2 years later
at the same level within the same artery.21 Details concerning the manipulation were not given. In another case, the
patient had received manipulation 2 weeks before the second dissection.27 Again, no confirmation of the manipulation itself or any details concerning the nature of the manipulation were given. Both dissections affected the ICA.
In only 2 other cases of recurrence was any trauma involved in the initial dissection. One case occurred following
a judo maneuver,21 and the second may have been the result
of a motor vehicle accident.29 No recurrences were reported
to have been the result of trauma, with the possible exception of 1 case where the recurrence occurred while the patient was awakening from anesthesia.
A patient who has had a CAD is often very concerned about
the possibility of recurrence and what steps can be taken to
avoid such a recurrence. The literature, however, provides
meager information that can be conveyed to such a patient.
The most significant information to come from this literature is the fact that recurrences do occur and that the primary
risk factors appear to be inherent rather than external. At this
time there is very little a patient can do to prevent a recurrence. However, family history and the presence of a previous dissection appear to be important risk factors.
The reported frequency of recurrences is approximately
1% per year, which is not insignificant. The likelihood of
recurrence based upon our review appears to be no greater
in the previously dissected artery than in the other previously
unaffected cervical arteries. Recurrences may also occur
in arteries other than cervical vessels, such as the aorta or
renal arteries.
A number of facts suggest that a patient’s predilection to
dissection continues after the initial dissection. The likelihood of dissection in a patient with a previous dissection
(1% per year) is considerably greater than in the population
as a whole, in which it is estimated that the risk is no more
than 2.6 to 2.9 per 100,000 per year for dissections of the
ICA.36 The observation that up to 50% of patients in one
study had a family history of arterial dissection and that
both initial and recurrent dissections are much more com-

mon in younger individuals suggests a genetic predilection.
This is supported by recent published biochemical and
genetic investigations of patients with a previous dissection.
Mayer et al18 described a point mutation of Type I collagen
that might have contributed to vascular fragility in a single
patient who had had a spontaneous dissection. Brandt et
al,19 in a more convincing article, performed skin biopsies
on 25 patients with spontaneous dissections to evaluate the
overall architecture and morphology of the connective tissue. They found that 68% of patients had ultrastructural
abnormalities resembling those found in Ehlers-Danlos syndrome. The function of connective tissue is to provide stability and elasticity to the vessel wall, and structural changes
in the collagen and elastic fibers could result in functional
impairment. These authors concluded that an underlying
inherited connective tissue arteriopathy might be the cause
of these dissections.19
Despite the correlation of a family history of dissection
with recurrent dissections and the association of heritable
connective tissue disorders with spontaneous dissections,
it remains difficult to identify who is at risk for an initial
dissection. In the study by Brandt et al19 in which aberrations of connective tissue were found, there was no other
history of a heritable connective tissue disorder. Brandt
et al stressed that “even assuming an underlying connective tissue disorder, it remains unclear why CAD occurs
at a certain point in time and at a distinct location and
why recurrence rate and family occurrence are quite
low.19”
It would appear that other factors may be necessary for a
CAD to occur. The kinking and tortuosity of the VA at the
level of the atlas and axis11 and the observation that tractioning and stretching of the internal carotid can occur at the
level of the atlas37,38 has led to the suggestion that mechanical injury or occlusion may be a precipitating factor in
CAD. However, if this was the only mechanism, one would
anticipate many more reported cases of dissection to either
the ICA or VA, given that over 200 million manipulations
are performed each year in the United States alone39 and
that most individuals will experience some form of cervical
trauma in their lifetime.

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Manipulation and Recurrent Arterial Dissection • Rubinstein and Haldeman

Although the literature on initial CADs does suggest a
correlation with trauma and manipulation,9 the most recent
data do not link trauma or spinal manipulation as the precipitating factor for recurrent dissection. Whereas up to 50% of
all initial vertebral artery dissections have been related to
some form of trauma, in only 2 cases (6%) of recurrent dissections was trauma the precipitating factor in the initial dissection, and in only 1 or 2 cases was there any speculation of
trauma as a precipitating cause of the recurrence. This may
reflect the fact that the majority of the cases in these reviews
concern carotid artery dissections, whereas the majority of
trauma-related dissections involve the VA. Regardless, it
does not appear that a history of traumatic CAD is a significant factor in the likelihood of recurrence. Trauma also does
not appear to be a significant precipitating factor in the risk
of recurrences.
A recent study has suggested that there may be a link
between CAD and recent generalized (systemic) infection,
independent of mechanical or genetic factors.31 It found that
58% of consecutive patients who presented with spontaneous CADs had experienced symptoms of infection, compared with the control group of patients with acute cerebral
ischemia from other causes (32%). They found that recent
infection was independently associated with CAD and not
the mechanical factors of coughing, sneezing, or vomiting.
They refer to the literature on the effects of inflammation
mechanisms of infection or the microbial agents themselves
on arterial wall integrity as the factors precipitating the dissection.40,41
To date, there have been just 5 cases reported in which
internal carotid dissection occurred after cervical manipulation. This is in stark contrast to the vertebrobasilar system,
in which more than 180 such cases have been reported.11 In
2 of the 5 cases of ICA dissection after manipulation there
was underlying pathology (atherosclerotic changes or
underlying arteriopathy)13,14; a congenital variation of the
vertebrobasilar system may have been a predisposing factor
in a third case.15 In the other 2 cases, however, there was
insufficient history to make any further comment.16,17 In
addition, 1 of these cases involved a patient who had a dissection 5 days after the manipulation,16 raising the issue of
whether the manipulation was responsible for the injury. At
this time there are insufficient data to make manipulation an
independent risk factor for internal artery dissection,
although it may precipitate ischemia in a patient who is in
the process of dissecting.

CONCLUSION
To our knowledge, there have been no previous case
reports of patients with prior CADs being subsequently
treated with cervical manipulation. The safety of manipulation for patients with prior dissections has not been adequately discussed in the literature. At present, we do not
know the nature of the risk because there are no other
reports of patients successfully undergoing cervical manipulation after a dissection. Our patient has undergone multiple
cervical manipulations over the past 3 years without any

adverse effects and has found the treatments to be beneficial. This should not be interpreted as meaning that it is safe
to manipulate patients with a history of dissection. There are
a number of factors that made it reasonable to consider
manipulation for this patient: the original dissection was due
to major trauma (ie, the forces causing the original injury
were much greater than any force that could possibly be
generated by a cervical manipulation); there were no other
risk factors present, such as history of connective tissue
abnormalities or a family history of vascular disease; and
the initial dissection was in the carotid artery, which is much
less susceptible to manipulation-related trauma than the vertebral artery. Nonetheless, we felt it was important to inform
the patient of the perceived risks on at least 2 occasions
before attempting manipulation; to try other less traumatic
forms of treatment for an extended period before manipulation; and to explain our lack of understanding of the likely
outcome of manipulation in this case. Based on her previous
experience, this patient felt that the benefits of the treatment
outweighed the potential harm. She was willing to accept
our lack of understanding and our inability to present information regarding the risks associated with treatment. After
receiving the manipulative treatments this patient felt that
she had made the correct decision. She achieved greater and
quicker relief of symptoms through manipulation than she
was able to obtain from other treatment methods or pharmacologic agents.

ACKNOWLEDGMENT
Sidney Rubinstein would like to thank his wife for her
support and her valuable comments in the preparation of
this manuscript.

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Manipulation and Recurrent Arterial Dissection • Rubinstein and Haldeman

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