We present a case of a 14-year-old female with known vascular Ehlers Danlos Syndrome (EDS) who presented with left-sided weakness and sensory loss, dysarthria, and visual complaints after chiropractic manipulation.

Vascular EDS is an autosomal-dominant connective tissue disorder that predisposes individuals to arterial and hollow organ rupture and is caused by a pathogenic genetic mutations in COL3A1, encoding type III collagen. Dissections in patients with EDS can be spontaneous or caused by minor trauma.  Complications following chiropractic manipulations are rare, however they can be severe such as extracranial arterial dissection (commonly vertebral artery dissection (VAD)), stroke, CSF leak and even death. There are limited case reports of ICA dissection as a complication of chiropractic manipulation. 

The patient presented for left-sided weakness and sensory loss, slurred speech, and visual complaints that resolved after 2 hours. Her neurological exam was normal at the time of presentation. She denied recent illness and head or neck trauma, however reported that a few months prior she had chiropractic manipulation of her neck.  MRI brain showed no infarcts, but MRA brain/neck indicated significant right internal carotid artery stenosis at the junction of the cervical and petrous segments with linear defects suggesting dissection. We suspected traumatic dissection from chiropractic manipulation. Other differentials such as spontaneous dissection and coagulopathy were also considered. Thrombophilia work-up and Platelet Function Assay (PFA) were normal. Systemic anticoagulation was initiated due to high stroke risk. Heparin was switched to apixaban upon discharge and later transitioned to antiplatelet therapy with aspirin after completing 3 months of anticoagulation. 

Manipulations of the head and neck should be avoided in patients with connective tissue disorders. While the initial presentation may be asymptomatic, there is a risk of progression, which may occur in a delayed fashion and can present as transient neurological symptoms or devastating ischemic stroke.