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After subsequent chiropractic cervical manipulation, CT angiography demonstrated distal intradural vertebral artery dissection with bilateral cervical internal carotid artery aneurysms. Because vascular imaging was not obtained before chiropractic manipulation, the temporal relationship between strangulation, manipulation and CAD cannot be established. This illustrates the challenge of attributing cerebrovascular injury in patients exposed to multiple insults and supports careful clinical assessment and a lower threshold for vascular imaging in selected patients with persistent symptoms following strangulation-related trauma.<\/jats:p>","DOI":"10.1136\/bcr-2026-275291","type":"journal-article","created":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T11:15:22Z","timestamp":1787570122000},"page":"e275291","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Cerebrovascular injury following manual strangulation and subsequent cervical manipulation: challenges in attribution and imaging decisions"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-7683-0563","authenticated-orcid":false,"given":"Patrick John","family":"Reese","sequence":"first","affiliation":[{"name":"Family and Community Medicine, The University of Oklahoma School of 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