Cerebrovascular injury following manual strangulation and subsequent cervical manipulation: challenges in attribution and imaging decisions.

Cervical artery dissection (CAD) causes approximately 2% of ischaemic strokes overall but up to 25% in adults younger than 50 years. Isolated head or neck pain without infarction occurs in 8%-12% of cases and may contribute to delayed diagnosis. CAD has been described following manual strangulation and chiropractic manipulation. A woman in her 30s who presented with persistent headache following repeated intimate partner violence-related strangulation was initially discharged after a negative head CT. After subsequent chiropractic cervical manipulation, CT angiography demonstrated distal intradural vertebral artery dissection with bilateral cervical internal carotid artery aneurysms. Because vascular imaging was not obtained before chiropractic manipulation, the temporal relationship between strangulation, manipulation and CAD cannot be established. This illustrates the challenge of attributing cerebrovascular injury in patients exposed to multiple insults and supports careful clinical assessment and a lower threshold for vascular imaging in selected patients with persistent symptoms following strangulation-related trauma.