cervical arterial dysfunction · how might arterial complications occur? • vasospasm •?linked...
TRANSCRIPT
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Cervical arterial dysfunction ... Beyond VBI & Manipulation (Part1)
Alan Taylor MSc MCSP
Roger Kerry MSc MMACP MCSP
Trondheim 2013
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= Pain
= Brain ischemia
Understanding the mechanisms?
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Understanding the pathology
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Improving clinical reasoning ….
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Thinking about these cases?
• NMS Worst case scenario
• Worst case scenario NMS
• **Medical model??
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Worst case scenario?
• Death …..
• Stroke …..
• Loss of sight ….
• TIA ….
BUT …. What are the potential clinical scenarios?
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Vascular terminology
• Stenosis – narrowing – Atherosclerosis
– Small vessel disease
• Occlusion - Blockage
• Haemorrhage – bleeding
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• Dissection – damage to vessel
– Spontaneous
– Traumatic
• Distal embolisation
• Systemic vasculitis (i.e. Temporal arteritis)
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Haemodynamics of the cervical vessels
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Tunica adventita (external coat)
Fibrous connective tissue
provides strength to vessel walls
maintains shape of vessels
**transmits pain perception**
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Mechanisms of cervical arterial pathology
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MANUAL THERAPISTS
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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
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TRAUMA!
Traumatic ICA dissection associated with triathlon Sportverletz Sportschaden 2005 19(4); 211-13
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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
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CAROTID ARTERY KINKING DURING ROTATION
Carotid artery
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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
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Dissection
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Aneurysm
50% increase in normal diameter
Clinical symptoms arise from
rupture
thrombosis
distal embolisation
May affect any vessel
Carotid
Vertebral
Subclavian
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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)).
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Virchow’s Triad
Stasis
Vessel wall
injury
Clotting abnormalities
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Kinking
Turbulent Flow
Altered
Haemodynamics
Biomechanics?
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Vessel wall
injury
Predisposing factors
Altered haemodynamics
THROMBOSIS
MODIFIED VIRCHOW’S TRIAD
Symons & Westaway J Can Chiropr Assos 2001;45(4)
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RISK BENEFIT
LOW MOD HIGH
MANUAL THERAPY
VASCULAR RISK CATEGORY
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Diagnostic methods
• Subjective history***
• Enhanced index of suspicion
• Clinical examination***
• Duplex ultra sound
• Arteriogram
• MRA
• CTA
• Post mortem!
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= Pain (vessel wall) primary symptom
= Brain ischemia (latent) secondary
Understanding the mechanisms?
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Questions?
Questions