Clinical update
The etiology of cervical artery dissection

https://doi.org/10.1016/j.jcme.2007.04.007Get rights and content

Abstract

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.

Introduction

The etiology of cervical artery dissection (CAD) is, for the most part, unclear; and what has been proposed as an explanation for its pathogenesis is largely hypothetical.1 Furthermore, when dealing with a particular case of CAD, the pathogenesis is especially speculative.2 Nevertheless, a number of risk factors have been reported to be associated with the condition, including connective tissue abnormalities, hypertension, recent infection, migraine headache, the use of oral contraceptives, and others. Of special interest to chiropractors is the role cervical spine manipulation (CSM) plays, if any, in the pathogenesis of CAD. Indeed, patients do experience CAD on rare occasions after CSM, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition important for chiropractors.

Section snippets

Anatomy of the cervical arteries

The understanding of CAD is greatly enhanced by having a basic grasp of the relevant anatomy. A pair of vertebral arteries (VAs) and a pair of internal carotid arteries (ICAs) pass through the cervical region to supply the brain with blood. The ICAs and their branches are often referred to as the anterior circulation because they supply blood to the anterior portion of the brain. The vertebral and basilar arteries comprise the vertebrobasilar system, which is referred to as the posterior

Mechanisms of dissection

The VA seems most susceptible to strain in the atlantal segment as it traverses the C1-2 articulation,30 where it seems most at risk during rotational movements.6 The proposed mechanism of arterial strain during neck rotation involves the ipsilateral C1-2 joint being fixed while the contralateral side of C1 is propelled forward, which compresses and stretches the artery. The ICA is most susceptible to strain in the upper cervical region when the head and neck are in combined rotation or lateral

Conclusion

The cervical arteries are susceptible to dissection in association with a variety of trivial events. This association is confusing, however, because people normally encounter innumerable trivial events during their lifetime without ever experiencing dissection. Moreover, patients do not live in a vacuum and are typically exposed to other potentially contributory incidents before and after an event that is suspected of causing a particular CAD. For instance, they turn their heads to back up

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      However, the intensity of the trauma necessary to initiate the lesion remains a question of debate especially when low-energy injuries are involved. Many authors hypothesize that given the large occurrence of neck movements in all sorts of activities and the high frequency of infection in the population, minor traumas do not cause CAD in most individuals.11,17,18 According to these authors, people who undergo a CAD with or without minor trauma likely have an underlying pathological process, be it an arteriopathy, an inflammation, or structural weakness of the artery wall that leads to dissection.

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      Similarly, a review published in 2012 found the evidence inadequate to either confirm or refute a significant association between manipulation of the cervical spine and stroke.13 Efforts to identify either risk factors or populations at risk for VBS have been largely unsuccessful.14,15 The risk of stroke in general increases with age,16 but it is not known how age might affect the risk of stroke after spinal manipulation.17

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