Cervical arterial dysfunction · How might arterial complications occur? • Vasospasm •?linked...
Transcript of Cervical arterial dysfunction · How might arterial complications occur? • Vasospasm •?linked...
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)
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