Internal carotid artery dissection following chiropractic treatment in a pregnant woman with Systemic Lupus Erythematosus

Dissection of the internal carotid artery accounts for approximately 20% of cases of ischaemic stroke in young adults. A population-based study reported the average annual incidence rate for spontaneous internal carotid artery dissection was 1.72 per 100 000 individuals [1]. Several vascular and connective tissue disorders have been associated with dissection, in particular migraine, fibromuscular hyperplasia and vascular Ehlers-Danlos syndrome. In addition, a number of physical activities have been associated with dissection. It remains unclear as to whether chiropractic neck manipulation is associated with craniocervical artery dissection. This paper describes a case of internal carotid artery dissection following chiropractic treatment in a pregnant woman with Systemic Lupus Erythematosus. The possible contributing factors in this case are discussed.A thirty-one year old woman, pregnant at 16 weeks gestation, presented to a chiropractor for treatment of occipital headache. She had suffered with intermittent bilateral occipital muscle tension headaches occurring monthly since the age of 14 years. The frequency of headache was unchanged during pregnancy. In addition she had a history of migraine characterised by unilateral frontal headache, the last episode of which had been 6 weeks earlier. There was no recent history of viral illness and no family history of stroke. The subjects history was also significant for Systemic Lupus Erythematosus (SLE) diagnosed twelve years earlier, complicated by renal involvement treated with azathioprine and prednisone, hypertension managed with labetalol, and episodes of deep vein thrombosis and pulmonary embolism. She was heterozygous for prothrombin gene mutation but did not have a lupus anticoagulant or anticardiolipin antibody.Immediately after receiving treatment the subject noted severe right sided anterior neck pain, and rapidly developed ipsilateral Horner’s syndrome. It was not possible to obtain exact information regardin