OBJECTIVE: To discuss the use of magnetic resonance angiography (MRA) imaging as a definitive means to assess vascular patency and the relative value of various vertebral artery screening maneuvers.

CLINICAL FEATURES: Two female patients suffered head and neck trauma with possible vertebral artery insufficiency. Positive vertebral artery screening tests with consistent symptoms were present in both cases. One patient had a congenitally narrowed vertebral artery, whereas the second had no evidence of vascular anomaly.

INTERVENTION AND OUTCOME: Conservative chiropractic management using manipulation and rehabilitation led to favorable outcome in both cases. The patient with vascular compromise received a treatment plan avoiding neck manipulation. The second case received manipulation per clinical indications from neck findings.

CONCLUSION: MRA imaging may be more important to critical decision making than are the various vertebral artery screening tests in patients with positional vertigo on combined neck extension and rotation.

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