@2024 Afarand., IRAN

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ISSN: 1027-1457    Scientific Journal of Forensic Medicine 2019;25(2):105-108

Background
Neck arteries dissection (carotid and vertebral) is known as one of the causes of stroke which often occurs after a neck trauma.
Previous Studies
Vertebral artery dissection (VAD) may originate from the neck and extend to the intracranial portion of the artery. Severe and rapid rotational movement is the most common trauma in VAD, like the head backwards when the car is in reverse gear. Cervical spine manipulation, straightening of the neck for head washing, and direct trauma to the neck are predisposing causes. Severe coughing can also lead to dissection, and in most cases the trauma is so minor that it may not be noticed or remembered by the physician. . There is no gender superiority and men and women are affected equally. Vascular wall weakness due to connective tissue diseases, such as Ehlers–Danlos syndrome and fibromascular dysplasia are considered as risk factors. Dissection usually originates from the C1-C2 segment of the neck arteries, where the artery has the most motility. When dissected, it forms inside the clot vessel and moves through the bloodstream to the distal arteries, leading to vessel obstruction and causing infarction [1].
Aim(s)
This study was a case report of a vertebral artery dissection in a young woman following a neck manipulation in order to treat a headache by a local therapist.
Research type
This study was a case-report study.
Research society, place and time
The patient was a 27 years old woman with migraine headaches who was referred to the Neurology Clinic in 2017.
Sampling method and number

Used devices&materials

Findings by Text
The patient's headaches occasionally existed for several years, with nausea and vomiting and photophobia and were pulsing. Headaches have increased in the last month. On examination, body temperature was 37 ° C, blood pressure was 120.80 mmHg and heart rate was 70 min. Neurologic examination of the cranial nerves was normal and fundoscopic examination showed the disk with sharp margins in patient with no papillary edema. There was no neck stiffness. Motor system examinations included normal limb strength. Tendon Reflexes were 2 and foot reflex was flexor. Therefore, the neurological examination was normal and the neurologist requested brain imaging after examination due to recent exacerbation of headaches and a brain CT scan was performed that was not included any pathological findings. Therefore, the patient was discharged with migraine diagnosis and administration of nortriptyline, propranolol and risatriptan and she was advised to come back one month later. Ten days after the neurologist's examination, the patient was brought to the hospital with low level of consciousness. According to the history taking, the patient was at a party and, after returning from the party, first she had a headache followed by a lowered level of consciousness and she then brought to the hospital. At the hospital examination, the patient's blood pressure was 100.60 mm Hg, body temperature was 37.5 ° C, heart rate was 75, and respiratory rate was 22. Arterial oxygen saturation was 2%. The patient was weakly localized painful stimulation with her right hand. The oculocephalic reflex had disappeared. The pupils showed normal reaction to the light. Tendon Reflexes were increased and with clonus (+ 4). Given the possibility of drug poisoning, the patient underwent gastric lavage, but only food fragments without drug residues and patient's companions also gave no history of psychiatric disorders or family problems. A brain CT scan was performed that had no specific findings. Due to low level of consciousness and respiratory status, the patient was intubated and was admitted to the intensive care unit and investigating the cause of disease was continued. In the initial laboratory studies, the electrolytes and blood glucose were all normal and in the blood cells tests, hemoglobin was, 13 g / dl, white blood cell count was 13,500 and platelet count was 274,000. At first, botulism was suspected due to the clinical condition of the patient after eating dinner at party. However, after a asking about the type of food and the absence of another person at the party with similar problem and also clinically, no involvement of pupils was observed (a diagnostic feature of botulism), so diagnosis did not seem likely. The patient underwent mechanical ventilation and investigations were continued for the cause of consciousness loss and the brain MRI was performed. The MRI showed ischemic infarction in the pons and cerebellum of the patient (Figure 1). The patient had no vascular risk factors for stroke and blood tests showed no specific findings. The patient's vasculitis tests were negative. Cardiac consultation was performed and the echocardiography and ECG of the patient were normal. The cardiac cause for arterial embolism was therefore ruled out. Brain angiography was performed on the patient for brain examination (Figure 2). Magnetic resonance angiography showed the cut vertebral artery and in the following CT scan, vertebral artery dissection was confirmed. Vertebral artery dissection mainly occurs following trauma to the neck, but the patient did not have a history of trauma. However, a detailed query from the patient’s companion revealed that the patient had been referred to a local therapist to treat the headache and he with a stick and rope affected her neck and the patient has faced loss of consciousness almost an hour later.
Main comparison to the similar studies
The causes and conditions that cause vertebral and carotid artery dissection are crucial from forensic perspective, when they are diagnosed when a person experiences a minor trauma such as a stroke, cough and Valsalva maneuver. In addition, this diagnosis should be taken into account when a person experiences post-traumatic consciousness failure and examination of the common causes of coma are not effective. In cases of hanging, due to the pressure applied to the carotid artery, this diagnosis should be considered [3, 4] and if there is any doubt in this regard, the neck arteries should be examined by Doppler ultrasound [5]. … [6].
Suggestions

Limitations

Conclusions
Neck arteries dissection as one of the causes of neurologic deficit and decrease the level of consciousness should be considered in patients with minor or severe trauma. After this diagnosis, the existence of trauma in the patient examination should be considered. Trauma may have a legal significance.
Acknowledgments
The authors are grateful and grateful for the cooperation of all those who assisted in this research.
Conflict of interest
None declared.
Ethical Permissions
Due to the observe confidentiality and lack of medical intervention on humans, there was no need to devise a code of ethics.
Funding Sources
None declared.

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