Vertebral artery dissection and cerebellar infarction following chiropractic manipulation ▸

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Due to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand and walk. Vertigo and disequilibrium are usual presenting symptoms in emergency department (ED), which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or hemorrhage. Although rarely seen in young adults, the last two due to traumatic or spontaneous arterial injury—including injury secondary to chiropractic cervical manipulation may occur. A number of cases about VAD associated with chiropractic cervical manipulation have been reported, but rarely in emergency medicine literature. In the case report, we discuss this rare occurrence, with emphasis on the diagnostic pitfalls in ED.

http://emjonline.com/cgi/content/full/23/1/e1. doi: 10.1136/emj.2004.015636

How ECG can cause confusion in pulmonary embolism and how echocardiogram can help ▸

Most deaths from pulmonary embolism (PE) occur because of a delay in diagnosis. ECG changes suggesting cardiac ischaemia can cause confusion but is well recognised in massive PE. In these cases early echocardiogram is important especially in the presence of hypotension/collapse. The case highlights the value of an early use of echocardiogram in the diagnosis of acute massive PE.

Most ECG features in PE lack specificity and sensitivity and the value of ECG for the diagnosis of PE is debatable. Once the diagnosis of PE has been established, the ECG could allow the massive forms to be distinguished. Echocardiography can be helpful …