Neuroradiologist here. There is quite a bit of streak artifact obscuring the distal vertebral arteries as well as some venous contamination and while the interpreting radiologist could be given some slack for having not detected the distal left vertebral artery dissection, what is not obscured is the basilar artery that is clearly occluded through much of its proximal extent- an unfortunate missed finding that should have been made. As a radiologist, I cannot say whether or not it would have made a difference in the patient's outcome so I would defer to the expertise of others to speculate on that.
Also, while I agree you could make a case for possible right vert dissection, the transverse foramina on the right are small indicating this is likely just a normal variant, congenitally diminutive artery.
To clarify, when I say the interpreting radiologist could be given some slack for having not detected the distal left vert dissection, I do not mean that it is an understandable or acceptable miss. I'm just calling out the limitations and possible explanations for why something might have been missed. As CA_IR_Rad points out below, the V3 segment dissection is clearly visible. But the basilar occlusion was an even more obvious finding that should have been made.
Thanks for the comment! Very helpful. What do you think is the reason that there's contrast in the basilar past the obstruction? Is it back flowing from the anterior circulation? Or is there a tiny channel through the obstruction that's letting some contrast through and it's pooling distal to the occlusion?
Reviewed all the images and the cases you linked in Radiopedia- better ER doc for it now. Immense gratitude to the family for sharing the images of their loved for my learning. Disregarding my own opinions about how the case went (and chiropractors), the family has probably been through some awful times with all this.
Yes. I feel so terrible for them, and am deeply grateful that they're willing to share these images so that we can learn from. I genuinely feel that it could make a difference for other patients in the future. The education from this case is priceless, even if we don't agree with the legal outcome. I'm glad the family will get some financial help but I also don't think the ER doctor was grossly negligent. Chiro should take the biggest blame, followed by rads, followed by ER, followed by neuro.
Thank you for getting the images, the direct imaging is so important and we so rarely get to see it in most cases.
I am an IR fellow. As another factor that I think should have led to less distraction about the right vert, the clue that it is congenitally small is because the right transverse foramen is correspondingly also diminutive. Vert dissections can be extremely subtle sometimes only appearing as a subtle contour irregularity on one or two slices (but would be seen more clearly on a dissection protocol MRA neck, which likely could have been recommended here) however in this case the left vert is very abnormal and becomes string-like at 2 locations from distal to the C2 foramen to the proximal V4 segment which is not obscured by artifact (axial images 85 and 79 for example). Agree the basilar occlusion is a "can't miss"
Yep, totally agree that the imaging is critical. The #1 most frustrating thing about reviewing med mal cases in this forum is that the images are NEVER in any of the court documents. There's no mechanism to upload them into court databases, its PDF only.
Is this basilar obstruction something that warrant an attempt at thrombectomy? Does the fact that the right is tiny and the left has a dissection prevent access to it?
Not my subspecialty but I have discussed it with neuro IRs who would entertain treating this with thrombectomy, in this case there is definitely the added difficulty of the dissection but they could still approach via the left vert, stent the dissection, and then thrombectomize the basilar. Not an easy case but if technically achievable has been shown to have benefit over TPA alone, according to a couple RCTs which came out in 2022 (https://www.ahajournals.org/doi/10.1161/STROKEAHA.122.040807). I have also seen focal basilar occlusion treated successfully with heparin alone (in a patient with mild and improving symptoms). I think in 2015, when this patient presented, thrombectomy would have been available but unlikely it would've been considered standard of care. Not sure it would be considered standard of care now either.
I am a neurologist. I agree that the basilar occlusion is easy to spot. Unfortunately even the read was very obscure that a rushed ED doc could i be interpreted as “nothing acute”.
Not sure what year was this case but certainly the patient could have gone for mechanical thrombectomy has the basilar occlusion been identified. Despite the patient probably would’ve ended up with bad disability but maybe not locked in?
I feel chiropractors share most of the responsibility as this well documented risk and they still proceed with neck manipulation and doubt that any of them discuss this risk with their patients. Not arguing what benefit does neck adjustment do to the patient anyway!
Even an ED doc being very patient and thorough would not have appreciated it, given the read said the basilar was normal! Totally agree with you that chiro is the person who is at the biggest fault here.
With a dissection would you not need to stent the basilar (RIP) as it's the vessel wall not a retrievable thrombus inside the vessel? I just gas people for these procedures so I don't know shit
I'm also curious about this. I'm confused if the basilar occlusion is the dissected wall of the artery completely occluding it, or if it's actually a thrombus (turbulent flow across the dissected vert causes clot that migrates a few millimeters and gets stuck in the basilar?)
Would you try if you got consulted on this patient? Or if you're not a proceduralist who does this, have you seen your consultants try it for basilar obstruction / vert dissection?
In this case the entire vertebral artery is occluded, and the contralateral side is non-dominant and too small to fit any usable equipment. The basilar occlusion would be unlikely to be reachable.
Some people may try because they feel "everything should be done"... that is a common sentiment in the neuroradiology world.
Not the op but just eant to second, the obvious basilar occlusion is a massive misread. Something like that requires direct communication with the ordering provider. The pcas appear to be filling from pcoms. This really should have been on radiology, however if the stroke was likely already completed, wouldnt have made a difference. Looking at the ctas I suspect there was likely evidence on the ct head of completed stroke, however can't say for sure without looking at it. So likely this case proceeded forward on account of two misread studies.
CT head is linked lower down in the article if you'd like to look at it! I suspect the stroke wasn't completed at this point, as he made it to the ED within less than an hour of symptom onset if I remember it right. Still not clear if he would have been a candidate for even trying intervention, and if he did, outcome may have still been the same.
Ah, missed it. The CT actually looks ok however that area also tends to be compromised by artifact. Today absolutely this would be an interventional candidate. In 2015 while maybe not the standard of care, the institution I was working at definitely would have gone after this in the setting a poor exam (although granted they had/have very technically skilled interventionalists).
I've followed this case since your first write up and it's the main reason I started following you (from medicine Reddit). Very unfortunate for the family and it is commendable they agreed to share images so nothing but thanks and appreciation so it can contribute to the education of our field. I feel the chiropractor got off lightly compared to the ed physician and radiographer. Did the chiros house get repossessed too or is he still crackin' necks. Thanks medmal reviewer for all your efforts - appreciated.
Thanks! The is the best case I've published and it's not over yet... the bad faith lawsuit against the ER doc's med mal insurance company is still pending.
I don't know how much the chiro got off for, but he settled before trial so policy limits is not a bad guess. Who knows. I just checked and he's still out there advertising chiropractic services. Not sure if he's still crackin necks and rippin verts... should I send his office a message as a fake patient with neck pain and see if he'll crack my neck?!
Radiologist here. Intersting but very unfortunate case. The images are crucial to this case and now that we see the images, as people pointed out below, basilar artery occlusion should not have been missed.
Firstly, the CTA images are of the neck only. Not sure if actual CTA head and neck was ordered and we only have access to the neck images?
Second, the timing of contrast is delayed and the veins are also well opacified in the exam, which definitely limits evaluation. In addition, there are a lot more dental amalgam related artifacts. If I were reading this case in real time, I would not have appreciated the left vertebral artery dissection on my first pass. Nonetheless, basilar artery being occluded may have prompted me to take a second look at the vertebral arteries. There is a lot of venous contamination in the region of the dissection although "suboccipital rind sign" is definitely appreciated.
Third, the congenitally small right vertebral artery definitely is a distractor. It looks like the right vertebral artery ends in PICA and does not directly contribute to the basilar artery. This likely contributed to the basilar artery occlusion since the dominant blood supply (left vertebral artery) was dissected due to the chiropractic manipulation.
Lastly, we actually see a hint of left vertebral artery dissection on the noncontrast head CT at the edge of the images in retrospect. Would not have been able to call it prospectively on the noncon head CT.
The MRI clearly shows the findings well and it's a good reminder CT of the brain is not as sensitive compared to MRI due to the inherent limitation of the modality.
Good catch, I wrote CTA head/neck but its just the neck, thanks for pointing that out.
I had not realized how much artifact dental amalgam can cause until I looked at this. Guess it's just another way that not flossing/brushing can harm you!
I had not heard of suboccipital rind sign, excellent teaching point. If I'm understanding it right, I think I do see it at images 87 and 88 on the axials. For anyone reading this far into the comment section, I found this paper that helps illustrate this finding: https://www.ajnr.org/content/ajnr/early/2009/01/22/ajnr.A1455.full.pdf
Thanks for clarifying the right vert anatomy ending in PICA, that had me really confused. I did a little more reading and hadn't realized until now that it's a well described variant called PICA-VA. And that it's well known to be associated with vertebral hypoplasia... exactly the case here! https://pmc.ncbi.nlm.nih.gov/articles/PMC5386266/
I think I see what you're talking about on the head CT wo, very first axial image. Almost like a "hyperdense" sign immediately posterior to left C1.
You win the award for best teaching comment! If you're not already a paid subscriber and you want to be, send me a message and I'll comp you one. Really appreciate you.
Neuroradiologist here. There is quite a bit of streak artifact obscuring the distal vertebral arteries as well as some venous contamination and while the interpreting radiologist could be given some slack for having not detected the distal left vertebral artery dissection, what is not obscured is the basilar artery that is clearly occluded through much of its proximal extent- an unfortunate missed finding that should have been made. As a radiologist, I cannot say whether or not it would have made a difference in the patient's outcome so I would defer to the expertise of others to speculate on that.
Also, while I agree you could make a case for possible right vert dissection, the transverse foramina on the right are small indicating this is likely just a normal variant, congenitally diminutive artery.
To clarify, when I say the interpreting radiologist could be given some slack for having not detected the distal left vert dissection, I do not mean that it is an understandable or acceptable miss. I'm just calling out the limitations and possible explanations for why something might have been missed. As CA_IR_Rad points out below, the V3 segment dissection is clearly visible. But the basilar occlusion was an even more obvious finding that should have been made.
Thanks for the comment! Very helpful. What do you think is the reason that there's contrast in the basilar past the obstruction? Is it back flowing from the anterior circulation? Or is there a tiny channel through the obstruction that's letting some contrast through and it's pooling distal to the occlusion?
Reviewed all the images and the cases you linked in Radiopedia- better ER doc for it now. Immense gratitude to the family for sharing the images of their loved for my learning. Disregarding my own opinions about how the case went (and chiropractors), the family has probably been through some awful times with all this.
Yes. I feel so terrible for them, and am deeply grateful that they're willing to share these images so that we can learn from. I genuinely feel that it could make a difference for other patients in the future. The education from this case is priceless, even if we don't agree with the legal outcome. I'm glad the family will get some financial help but I also don't think the ER doctor was grossly negligent. Chiro should take the biggest blame, followed by rads, followed by ER, followed by neuro.
Thank you for getting the images, the direct imaging is so important and we so rarely get to see it in most cases.
I am an IR fellow. As another factor that I think should have led to less distraction about the right vert, the clue that it is congenitally small is because the right transverse foramen is correspondingly also diminutive. Vert dissections can be extremely subtle sometimes only appearing as a subtle contour irregularity on one or two slices (but would be seen more clearly on a dissection protocol MRA neck, which likely could have been recommended here) however in this case the left vert is very abnormal and becomes string-like at 2 locations from distal to the C2 foramen to the proximal V4 segment which is not obscured by artifact (axial images 85 and 79 for example). Agree the basilar occlusion is a "can't miss"
Yep, totally agree that the imaging is critical. The #1 most frustrating thing about reviewing med mal cases in this forum is that the images are NEVER in any of the court documents. There's no mechanism to upload them into court databases, its PDF only.
Is this basilar obstruction something that warrant an attempt at thrombectomy? Does the fact that the right is tiny and the left has a dissection prevent access to it?
Not my subspecialty but I have discussed it with neuro IRs who would entertain treating this with thrombectomy, in this case there is definitely the added difficulty of the dissection but they could still approach via the left vert, stent the dissection, and then thrombectomize the basilar. Not an easy case but if technically achievable has been shown to have benefit over TPA alone, according to a couple RCTs which came out in 2022 (https://www.ahajournals.org/doi/10.1161/STROKEAHA.122.040807). I have also seen focal basilar occlusion treated successfully with heparin alone (in a patient with mild and improving symptoms). I think in 2015, when this patient presented, thrombectomy would have been available but unlikely it would've been considered standard of care. Not sure it would be considered standard of care now either.
I am a neurologist. I agree that the basilar occlusion is easy to spot. Unfortunately even the read was very obscure that a rushed ED doc could i be interpreted as “nothing acute”.
Not sure what year was this case but certainly the patient could have gone for mechanical thrombectomy has the basilar occlusion been identified. Despite the patient probably would’ve ended up with bad disability but maybe not locked in?
I feel chiropractors share most of the responsibility as this well documented risk and they still proceed with neck manipulation and doubt that any of them discuss this risk with their patients. Not arguing what benefit does neck adjustment do to the patient anyway!
Even an ED doc being very patient and thorough would not have appreciated it, given the read said the basilar was normal! Totally agree with you that chiro is the person who is at the biggest fault here.
It's unlikely you can reach the basilar occlusion here. Mechanical thrombectomy would likely fail.
Doubtful there'd be any change in outcome.
Patient was doomed after the chiro manipulation.
With a dissection would you not need to stent the basilar (RIP) as it's the vessel wall not a retrievable thrombus inside the vessel? I just gas people for these procedures so I don't know shit
I'm also curious about this. I'm confused if the basilar occlusion is the dissected wall of the artery completely occluding it, or if it's actually a thrombus (turbulent flow across the dissected vert causes clot that migrates a few millimeters and gets stuck in the basilar?)
Would you try if you got consulted on this patient? Or if you're not a proceduralist who does this, have you seen your consultants try it for basilar obstruction / vert dissection?
In this case the entire vertebral artery is occluded, and the contralateral side is non-dominant and too small to fit any usable equipment. The basilar occlusion would be unlikely to be reachable.
Some people may try because they feel "everything should be done"... that is a common sentiment in the neuroradiology world.
Kudos to you for the effort to get these images
Not the op but just eant to second, the obvious basilar occlusion is a massive misread. Something like that requires direct communication with the ordering provider. The pcas appear to be filling from pcoms. This really should have been on radiology, however if the stroke was likely already completed, wouldnt have made a difference. Looking at the ctas I suspect there was likely evidence on the ct head of completed stroke, however can't say for sure without looking at it. So likely this case proceeded forward on account of two misread studies.
CT head is linked lower down in the article if you'd like to look at it! I suspect the stroke wasn't completed at this point, as he made it to the ED within less than an hour of symptom onset if I remember it right. Still not clear if he would have been a candidate for even trying intervention, and if he did, outcome may have still been the same.
Ah, missed it. The CT actually looks ok however that area also tends to be compromised by artifact. Today absolutely this would be an interventional candidate. In 2015 while maybe not the standard of care, the institution I was working at definitely would have gone after this in the setting a poor exam (although granted they had/have very technically skilled interventionalists).
Good to know, the current status of posterior circ thrombectomy isn't entirely clear to me but seems to be getting more and more prevalent.
I've followed this case since your first write up and it's the main reason I started following you (from medicine Reddit). Very unfortunate for the family and it is commendable they agreed to share images so nothing but thanks and appreciation so it can contribute to the education of our field. I feel the chiropractor got off lightly compared to the ed physician and radiographer. Did the chiros house get repossessed too or is he still crackin' necks. Thanks medmal reviewer for all your efforts - appreciated.
Thanks! The is the best case I've published and it's not over yet... the bad faith lawsuit against the ER doc's med mal insurance company is still pending.
I don't know how much the chiro got off for, but he settled before trial so policy limits is not a bad guess. Who knows. I just checked and he's still out there advertising chiropractic services. Not sure if he's still crackin necks and rippin verts... should I send his office a message as a fake patient with neck pain and see if he'll crack my neck?!
Radiologist here. Intersting but very unfortunate case. The images are crucial to this case and now that we see the images, as people pointed out below, basilar artery occlusion should not have been missed.
Firstly, the CTA images are of the neck only. Not sure if actual CTA head and neck was ordered and we only have access to the neck images?
Second, the timing of contrast is delayed and the veins are also well opacified in the exam, which definitely limits evaluation. In addition, there are a lot more dental amalgam related artifacts. If I were reading this case in real time, I would not have appreciated the left vertebral artery dissection on my first pass. Nonetheless, basilar artery being occluded may have prompted me to take a second look at the vertebral arteries. There is a lot of venous contamination in the region of the dissection although "suboccipital rind sign" is definitely appreciated.
Third, the congenitally small right vertebral artery definitely is a distractor. It looks like the right vertebral artery ends in PICA and does not directly contribute to the basilar artery. This likely contributed to the basilar artery occlusion since the dominant blood supply (left vertebral artery) was dissected due to the chiropractic manipulation.
Lastly, we actually see a hint of left vertebral artery dissection on the noncontrast head CT at the edge of the images in retrospect. Would not have been able to call it prospectively on the noncon head CT.
The MRI clearly shows the findings well and it's a good reminder CT of the brain is not as sensitive compared to MRI due to the inherent limitation of the modality.
Good catch, I wrote CTA head/neck but its just the neck, thanks for pointing that out.
I had not realized how much artifact dental amalgam can cause until I looked at this. Guess it's just another way that not flossing/brushing can harm you!
I had not heard of suboccipital rind sign, excellent teaching point. If I'm understanding it right, I think I do see it at images 87 and 88 on the axials. For anyone reading this far into the comment section, I found this paper that helps illustrate this finding: https://www.ajnr.org/content/ajnr/early/2009/01/22/ajnr.A1455.full.pdf
Thanks for clarifying the right vert anatomy ending in PICA, that had me really confused. I did a little more reading and hadn't realized until now that it's a well described variant called PICA-VA. And that it's well known to be associated with vertebral hypoplasia... exactly the case here! https://pmc.ncbi.nlm.nih.gov/articles/PMC5386266/
I think I see what you're talking about on the head CT wo, very first axial image. Almost like a "hyperdense" sign immediately posterior to left C1.
You win the award for best teaching comment! If you're not already a paid subscriber and you want to be, send me a message and I'll comp you one. Really appreciate you.