A 29-year-old male professional athlete presented to the emergency department complaining of visual changes. He described intermittent loss of vision in the right half of his visual field affecting only the right eye. The onset of the symptoms was approximately five minutes after neck manipulation by his chiropractor. While sitting in the chiropractor’s waiting room after the procedure he developed the above described visual change which persisted for approximately 15 minutes then resolved temporarily. He told the chiropractor of his symptoms and the chiropractor had him remain in the office for further observation. Within 30 minutes the same visual changes recurred, prompting the chiropractor to refer him for emergency department evaluation.

Upon initial evaluation in the ER, the patient was asymptomatic and had a completely normal neurologic exam to include visual fields to confrontation. Based on the history and presenting complaint, CT angiogram of the neck was ordered. While awaiting this study, the patient became suddenly symptomatic with recurrence of the same visual changes. Repeat neurologic exam at this time confirmed monocular right-sided hemianopsia with central sparing. Otherwise no associated neurologic deficits were noted.

CT angiogram confirmed the suspected diagnosis of cervical artery dissection. The radiologist commented on a less than 50% lesion in the right vertebral artery with no evidence of thrombosis. Noncontrast CT of the brain was normal. The inpatient neurology service was consulted to evaluate the patient at bedside. They initiated single-agent antiplatelet therapy with clopidogrel (Plavix) and admitted the patient for MRI/MRA to further clarify the lesion.

Magnetic resonance imaging demonstrated a 40% short segment dissection of the middle segment of the right vertebral artery without thrombosis (shown). MRI of the brain showed a punctate area of infarction in the occipital lobe.

Several weeks after the initial insult, the patient’s visual impairment had improved significantly with only modest subjective decrease in his peripheral vision on the affected side. It remains to be seen, however, if this residual deficit will hinder his career as a professional athlete.

Left vertebral artery dissection following chiropractic manipulation as seen on MRA

Left vertebral artery dissection following chiropractic manipulation as seen on MRA

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