Postpartum Vertebral Artery Dissection After Neck Massage Resulting in a Right Cerebellar Infarct: A Case Report and Literature Review

Vertebral artery dissection (VAD) can cause posterior-circulation ischemia after cervical manipulation; postpartum physiological changes may increase vascular vulnerability. A 30-year-old woman, nine months postpartum, developed an abrupt occipital headache, vertigo, nausea, and gait imbalance during a commercial neck massage. On examination, she had truncal ataxia and gait instability without focal limb weakness. We obtained 1.5-T MRI (diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC), T1-weighted imaging (T1), T2-weighted imaging (T2), fluid-attenuated inversion recovery (FLAIR), T2*/susceptibility-weighted imaging (SWI), and postcontrast 3D T1), time-of-flight magnetic resonance angiography (TOF-MRA), and computed tomography angiography (CTA). Imaging showed a right VAD with an intramural hematoma and luminal irregularity, right posterior inferior cerebellar artery (PICA) occlusion, and right-predominant cerebellar infarcts. A posterior fossa developmental venous anomaly (DVA) drained adjacent to the outlets of the fourth ventricle. Cerebellar swelling produced triventricular hydrocephalus with transependymal flow and early tonsillar descent. After multidisciplinary discussion, we initiated antithrombotic therapy, provided supportive care and a short course of corticosteroids for vasogenic edema, and preserved the DVA drainage. Neurosurgery placed an external ventricular drain for obstructive hydrocephalus; serial imaging documented regression of the edema and normalization of the ventricles. The patient improved but retained mild truncal ataxia at follow-up. Prompt vascular imaging should be obtained for acute posterior head or neck pain with neurologic signs after cervical manipulation. CSF diversion and edema control should be prioritized when posterior fossa mass effect arises, and DVA drainage should be preserved to avoid venous infarction.