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Qatar Med J. 2016; 2016(1): 8.
Published online 2016 June 15. doi:  10.5339/qmj.2016.8
PMCID: PMC4928106

Letter to the Editor

Brett Vaughan 1 , 2 ,

Dear Editor,

I read with interest the case report by Melikyan et al.,1 on a patient with a cervical artery dissection sparing the cortex. Case reports such as this do help to build a picture of the risk profile of any intervention used by a health professional. However, it is incumbent on authors of such reports to provide more accurate and detailed information about a case so as to inform readers and future research.

Unfortunately the report by Melikyan et al.,1 lacks key details and in part, misleads the reader. As identified in previous correspondence,2 a lack of detail about the intervention alleged to have caused the cervical artery dissection was missing. The authors did not explicitly state who performed the manipulation, nor the symptoms (beyond “chronic neck pain”) that may have lead the patient to seek some form of intervention. Further, the use of the term “chiropractic manipulation” in the title, and at times throughout the report, is misleading given the reader cannot make an informed judgement about the intervention provided. Tuchin3 has previously identified case reports where the intervention was described as a “chiropractic manipulation” however the person delivering the intervention was not a chiropractor.

It is recognized that a number of cardiovascular risk factors for cervical artery dissection are presented by the authors but a more extensive patient history would provide a clearer picture. A recent review4 identifies some further information that would be useful for the reader but was not presented in the case report. It may have been that the patient presented for care with a dissection in progress,3,5 rather than it being caused by the manipulation itself. From the information provided in the case report, it is difficult to identify if the relationship between the manipulation was temporal or causal, or whether the person providing the cervical spine manipulation had enough information to make an informed judgment about the appropriateness of this technique for the patient.

Case reports such as that by Melikyan et al.,1 do have a purpose and should continue to be published. The true risk profile of manipulation applied to the cervical spine can only be investigated when more detailed information is presented in future case reports, focusing on the symptoms that lead to the patient seeking cervical spine manipulation, a clear description of the practitioner who provided the intervention, and a detailed patient medical history focusing on those risk factors already identified in the literature.4 The CARE guidelines ( provide authors with a valuable starting point to ensure that all relevant information is included in a case report.

Author Response to Letter to the Editor

Chiropractic manipulation was performed in one of the private clinics of Doha during the last week of the event. Unfortunately, we were unaware if it was performed by a licensed chiropractor or not. This information was given by the patient's family. We agree that dissection can occur due to multiple etiological factors, but we ruled out all possible causes for dissection which have been included in the article (connective tissue disorder, infections, trauma, homocysteinemia etc.). We described the case as a result of chiropractic manipulation.


1. Melikyan G, Kamran S, Akhtar N, Deleu D, Miyares FR. Cortex-sparing infarction in triple cervical artery dissection following chiropractic neck manipulation. Qatar Med J. 2015;(2):16. [PMC free article] [PubMed]
2. Vaughan B, Thomson O. Valuable information about current clinical practice. Med Sci Law. 2014;54(4):236–237. [PubMed]
3. Tuchin P. Chiropractic and stroke: Association or causation? Int J Clin Pract. 2013;67(9):825–833. [PubMed]
4. Thomas LC, Rivett DA, Attia JR, Levi C. Risk factors and clinical presentation of cervical arterial dissection: Preliminary results of a prospective case control study. J Orthop Sports Phys Ther. 2015;45(7):503–511. [PubMed]
5. Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession. Chiropr Osteopat. 2010;18:22. [PMC free article] [PubMed]

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