Causal analysis of vertebral artery dissection and fatal stroke following chiropractic cervical spine manipulation

A 34-year-old female suffered a fatal stroke 7.5 h after cervical spine manipulation (CSM) performed by a chiropractic physician. Imaging noted vertebral artery dissection (VAD), basilar artery occlusion, and thromboembolic stroke. The medical examiner opined that CSM caused the VAD which embolized to cause the fatal stroke. However, causation of VAD by CSM is not supported by the research.

We utilized an intuitive approach to causation analysis to determine the cause of the VAD and the stroke. Causation of the VAD and the stroke by CSM could not be established as more likely than not. The malpractice case was settled by bringing allegations of misdiagnosis and failure to diagnose and refer the VAD to medical emergency.

We conclude that in the absence of convincing evidence that CSM could cause VAD, forensic professionals should consider VAD as a presenting symptom prior to CSM in such cases. Adherence to the standard of care for the chiropractic profession with attention to differential diagnosis could prevent such cases.