Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, the authors focused on the differential diagnosis, reviewing the available evidence.
A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section.
The authors concluded that vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.
In the discussion section, the authors point out that the incidence of VAD in pregnancy is twice as common as in the rest of the female population. They also mention that a review of the literature regarding adverse effects of spinal manipulation in the pregnant and postpartum periods identified adverse events in five pregnant women and two postpartum women. The authors also include a table that summarizes all cases of VAD reported both prior and after delivery, with 24 cases distributed with a prevalence during the postpartum period (19 of the 24 cases). The clinical presentation of these cases is varied, with a higher frequency of headaches, vertigo, and diplopia, and the risk factors most represented are hypertension and migraines.
The authors finish with this advice: practitioners who do spinal manipulations should be aware of the possible complications of neck manipulation in pregnancy and the postpartum period, particularly in mothers with underlying medical disorders that may predispose to vessel fragility and VAD.
I would add advice of a different nature: consumers should always question whether the risks of any intervention outweigh its benefit. In the case of neck manipulations, the answer is not positive.