Cervical arterial dysfunction ... Beyond VBI & Manipulation (Part1)

Alan Taylor MSc MCSP

Roger Kerry MSc MMACP MCSP

Trondheim 2013

= Pain

= Brain ischemia

Understanding the mechanisms?

Understanding the pathology

Improving clinical reasoning ….

Thinking about these cases?

• NMS Worst case scenario

• Worst case scenario NMS

• **Medical model??

Worst case scenario?

• Death …..

• Stroke …..

• Loss of sight ….

• TIA ….

BUT …. What are the potential clinical scenarios?

Vascular terminology

• Stenosis – narrowing – Atherosclerosis

– Small vessel disease

• Occlusion - Blockage

• Haemorrhage – bleeding

• Dissection – damage to vessel

– Spontaneous

– Traumatic

• Distal embolisation

• Systemic vasculitis (i.e. Temporal arteritis)

http://education.yahoo.com/reference/gray/subjects/subject?id=143

Haemodynamics of the cervical vessels

Tunica adventita (external coat)

Fibrous connective tissue

provides strength to vessel walls

maintains shape of vessels

**transmits pain perception**

Mechanisms of cervical arterial pathology

MANUAL THERAPISTS

How might arterial complications occur?

• Vasospasm • ?linked to stretch/compression

• May lead to cerebral ischaemia

• Haemostasis • platelet aggregation may lead to thrombogenesis

• Endothelial injury • As a result of minor trauma

• Frank arterial injury – dissection

• Haemorrhage – leading to obstruction

• Altered haemodynamic flow Thrombogenesis

Later embolus

Mann and Refshauge 2001 Aus J of Physiotherapy 47:255-266

TRAUMA!

Traumatic ICA dissection associated with triathlon Sportverletz Sportschaden 2005 19(4); 211-13

Mechanisms of arterial trauma

• “Spontaneous” – Cough/sneeze, vomiting, cervical rotation

• Road traffic accidents

• Manipulation

• Sport – Trauma i.e. Hockey, yoga

– Bow hunter (archery)

• Industrial accidents

• “Soft tissue massage”

• Hair salon syndrome

• Strangulation/domestic abuse

• Iatrogenic – Insertion of endotracheal tube

CAROTID ARTERY KINKING DURING ROTATION

Carotid artery

Arterial dissection

• Occurs when blood penetrates the intima and extends within the wall

• A sub intimal haematoma may may cause luminal narrowing or occlusion

• Sub-adventitial penetration may cause aneurysmal dilation – Known to lead to SAH

Dissection

Aneurysm

50% increase in normal diameter

Clinical symptoms arise from

rupture

thrombosis

distal embolisation

May affect any vessel

Carotid

Vertebral

Subclavian

Arterial Disease Carotid artery disease increases the risk of stroke in 3 ways: •By fatty deposits called plaque severely narrowing the carotid arteries. •By a blood clot becoming wedged in a carotid artery narrowed by plaque. •By plaque breaking off from the carotid arteries and blocking a smaller artery in the brain (cerebral artery)).

Virchow’s Triad

Stasis

Vessel wall

injury

Clotting abnormalities

Kinking

Turbulent Flow

Altered

Haemodynamics

Biomechanics?

Vessel wall

injury

Predisposing factors

Altered haemodynamics

THROMBOSIS

MODIFIED VIRCHOW’S TRIAD

Symons & Westaway J Can Chiropr Assos 2001;45(4)

RISK BENEFIT

LOW MOD HIGH

MANUAL THERAPY

VASCULAR RISK CATEGORY

Diagnostic methods

• Subjective history***

• Enhanced index of suspicion

• Clinical examination***

• Duplex ultra sound

• Arteriogram

• MRA

• CTA

• Post mortem!

= Pain (vessel wall) primary symptom

= Brain ischemia (latent) secondary

Understanding the mechanisms?

Questions?

Questions