Rozaleen Aleyadeh, Marialuisa Zedde, João Pedro Marto, Nils Henninger, Jamil Said, Jennifer Frontera, Richa Sharma, Ronen R. Leker, Thaís Secchi, Fransisca Indraswari, Abid Quereshi, Lily W. Zhou, Alexandre Y Poppe, Hipolito Nzwalo, Victor Carrasco Wall, Ana C. Fonseca, Piers Klein, David S. Liebeskind, S. O. Martins, Malik Ghannam, Vishnu Dantu, Jorge G. Ortiz Gracia, Giovanna De Marco, Ekaterina Bakradze, Mary Penckofer, Anvesh Balabhadra, Setareh Salehi Omran, Christopher Chang, Christopher R. Leon Guerrero, Varsha Muddasani, Regina von Rennenberg, Xiaofan Guo, Cheran Elangovan, Mohammad AlMajali, Faddi Saleh Velez, Reza Bavarsad Shahripour, Daniel M Mandel, Adeel Zubair, Marwa Elnazeir, Balaji Krishnaiah, Christoph Stretz, Shadi Yaghi, Nancy Maalouf
OBJECTIVES: Cervical artery dissection (CeAD) is an important cause of ischemic stroke in young adults. Nearly 100 million annual chiropractic cervical manipulations are performed in the United States. The relationship between manipulation and CeAD remains controversial. METHODS: We analyzed patients in the multicenter STOP-CAD registry (n=4023) to identify CeAD cases diagnosed after chiropractic cervical manipulation. Demographics and clinical features were compared between manipulation-associated and nonmanipulation-associated cases using χ 2 and t tests. Multivariable logistic regression identified key factors associated with manipulation-related CeAD. RESULTS: About 1 in 20 CeAD cases in this registry reported antecedent cervical manipulation. In multivariable binary logistic regression, compared with patients without prior manipulation, those with prior manipulation were younger (OR per year 0.98, 95% CI: 0.97-0.99, P =0.014), more often female (OR: 1.64, 95% CI: 1.21-2.23, P =0.001), less often diabetic (OR: 0.24, 95% CI: 0.08-0.78, P =0.018), presented with neck pain (OR: 2.80, 95% CI: 2.08-3.77, P <0.001), and had higher odds of isolated vertebral artery dissection (OR: 2.15, 95% CI: 1.57-2.94, P <0.001). Recurrent ischemic stroke rates were similar between groups. CONCLUSIONS: Given the very high number of manipulations performed annually, the absolute risk of secondary CeAD is extremely low. Manipulation-associated cases have distinct clinical features, occurring more often in younger women with vertebral dissections. Whether manipulation acts as a precipitating trigger or patients with early CeAD symptoms seek manipulation remains unresolved.