Stroke in a 33-year-old is rare enough to prompt scrutiny of any plausible precipitating event — and when that event involves cervical manipulation, the case lands in one of medicine's most contested causal debates. This report sharpens the clinical picture for practitioners and health-aware adults who seek chiropractic care for headache or neck pain, the very symptoms that may themselves signal an evolving vascular catastrophe.
The patient presented with progressive left-sided headache, neck pain, nausea, and left arm paresthesia — a constellation initially attributed to migraine at urgent care, delaying definitive diagnosis. Computed tomography angiography ultimately revealed both a vertebral artery aneurysm and pseudoaneurysm; MRI confirmed an acute lacunar infarct in the left cerebellar hemisphere; and MRA established bilateral vertebral artery dissection (VAD). A patent foramen ovale was also identified via transesophageal echocardiography, introducing an additional embolic pathway. Management centered on dual antiplatelet therapy rather than surgical intervention. Critically, the authors note the temporal association with recent chiropractic neck manipulation while explicitly declining to assert causation.
The vertebral artery dissection–cervical manipulation nexus has been debated in the literature for decades without resolution. VAD can occur spontaneously, and patients often seek care for the prodromal neck pain and headache of a dissection already underway — making it plausible that manipulation is a correlate rather than a cause in some cases. Population-level studies, including a 2015 JAMA Internal Medicine analysis, found no significant excess stroke risk attributable to chiropractic visits beyond what was seen with primary care visits for the same complaints. That said, biomechanical case series and vascular imaging studies do document arterial wall stress from high-velocity cervical thrust techniques. This single case report cannot resolve the debate — it lacks a control condition and relies on patient self-report of manipulation history. Its real clinical value lies elsewhere: it underscores that migraine-overlapping symptoms in young adults warrant vascular imaging when red flags such as neck pain, paresthesia, or gait instability are present, regardless of presumed etiology.