Selected Topics: Neurological Emergencies| Volume 63, ISSUE 1, P49-57, July 2022

Download started.


Cervical Artery Dissections and Ischemic Strokes Associated with Vascular Neck Compression Techniques (Sportive Chokes)



      Strangulation as a fight-finishing maneuver in combat sports, termed “choking” in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur.


      Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research.


      Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke.


      Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training.


      Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stellpflug SJ
        • Menton WH
        • LeFevere RC.
        Analysis of the fight-ending chokes in the history of the Ultimate Fighting ChampionshipTM mixed martial arts promotion.
        Phys Sportsmed. 2022; 50: 60-63
        • Stellpflug SJ
        • Menton WH
        • Dummer MF
        • Menton T
        • Corry J
        • LeFevere R.
        Time to unconsciousness from sportive chokes in fully resisting highly trained combatants.
        Int J Perform Anal Sport. 2020; 20: 720-728
        • Stellpflug SJ
        • Menton TR
        • Corry JJ
        • Schneir AB.
        There is more to the mechanism of unconsciousness from vascular neck restraint than simply carotid compression.
        Int J Neurosci. 2020; 130: 103-106
        • Lim LJH
        • Ho RCM
        • Ho CSH.
        Dangers of mixed martial arts in the development of chronic traumatic encephalopathy.
        Int J Environ Res Public Health. 2019; 16: 254
        • Stellpflug SJ
        No established link between repeated transient chokes and chronic traumatic encephalopathy related effects. No Established Link between Repeated Transient Chokes and Chronic Traumatic Encephalopathy Related Effects. Comment on Lim, L.J.H. et al. Dangers of Mixed Martial Arts in the Development of Chronic Traumatic Encephalopathy. Int. J. Environ. Res. Public Health 2019, 16, 254.
        Int J Environ Res Public Health. 2019; 16: 1059
        • Hubbard R
        • Stringer G
        • Peterson K
        • Filho Mario Roberto
        • Finnoff JT
        • Savica R.
        The King-Devick test in mixed martial arts: the immediate consequences of knock-outs, technical knock-outs, and chokes on brain functions.
        Brain Inj. 2019; 33: 349-354
        • Stellpflug SJ
        • LeFevere RC.
        Chokes in mixed martial arts. Comment on Hubbard et al. Brain Injury (2019; 33: 349-354).
        Brain Inj. 2019; 33: 959-960
        • Moriarty C
        • Charnoff J
        • Felix ER.
        Injury rate and pattern among Brazilian jiu-jitsu practitioners: a survey study.
        Phys Ther Sport. 2019; 39: 107-113
        • Stellpflug SJ
        • Schindler BR
        • Corry JJ
        • Menton TR
        • LeFevere RC.
        The safety of sportive chokes: a cross-sectional survey-based study.
        Phys Sportsmed. 2020; 48: 473-479
        • Stephenson C
        • Rossheim ME.
        Brazilian jiu jitsu, judo, and mixed martial arts injuries presenting to United States emergency departments, 2008–2015.
        J Prim Prev. 2018; 39: 421-435
        • Demartini Jr, Z
        • Rodrigues Freire M
        • Lages RO
        • et al.
        Internal carotid artery dissection in Brazilian jiu-jitsu.
        J Cerebrovasc Endovasc Neurosurg. 2017; 19: 111-116
        • Powell T
        • Fullam T
        • Hammett J
        • Nettlow D
        • Harris J.
        Vertebral artery dissection in active-duty soldier due to mixed martial arts choke hold.
        Fed Pract. 2018; 35: 12-17
        • Lannuzel A
        • Moulin T
        • Amsallem D
        • Galmiche J
        • Rumbach L.
        Vertebral-artery dissection following a judo session: a case report.
        Neuropediatrics. 1994; 25: 106-108
        • Slowey M
        • Maw G
        • Furyk J.
        Case report on vertebral artery dissection in mixed martial arts.
        Emerg Med Australas. 2012; 24: 203-206
        • McCarron MO
        • Patterson J
        • Duncan R.
        Stroke without dissection from a neck holding manoeuvre in martial arts.
        Br J Sports Med. 1997; 31: 346-347
        • Saw AE
        • McIntosh AS
        • Kountouris A
        • Newman P
        • Gaida JE.
        Vertebral artery dissection in sport: a systematic review.
        Sports Med. 2019; 49: 553-564
        • Schlemm L
        • Nolte CH
        • Engelter ST
        • Endres M
        • Ebinger M.
        Cervical artery dissection after sports - an analytical evaluation of 190 published cases.
        Eur Stroke J. 2017; 2: 335-345
        • Alexandrino GM
        • Damásio J
        • Canhão P
        • et al.
        Stroke in sports: a case series.
        J Neurol. 2014; 261: 1570-1574
        • Saw AE
        • McIntosh AS
        • Kountouris A.
        Vertebral artery dissection in sport: expert opinion of mechanisms and risk-reduction strategies.
        J Clin Neurosci. 2019; 68: 28-32
      1. Strokes, Carotid or Vertebral Artery Dissection in Jiu Jitsu Survivors. Facebook Group. Accessed June 13, 2021.

        • Lee VH
        • Brown Jr, RD
        • Mandrekar JN
        • Mokri B.
        Incidence and outcome of cervical artery dissection: a population-based study.
        Neurology. 2006; 67: 1809-1812
        • Arnold M
        • Kappeler L
        • Georgiadis D
        • et al.
        Gender differences in spontaneous cervical artery dissection.
        Neurology. 2006; 67: 1050-1052
        • Touzé E
        • Gauvrit J-Y
        • Moulin T
        • et al.
        Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study.
        Neurology. 2003; 61: 1347-1351
        • Atalay YB
        • Piran P
        • Chatterjee A
        • et al.
        Prevalence of cervical artery dissection among hospitalized patients with stroke by age in a nationally representative sample from the United States.
        Neurology. 2021; 96: e1005-e1011
        • Yafasova A
        • Fosbøl EL
        • Christiansen MN
        • et al.
        Time trends in incidence, comorbidity, and mortality of ischemic stroke in Denmark (1996–2016).
        Neurology. 2020; 95: e2343-e2353
        • Acharya V
        • Chandrasekaran S
        • Nair S.
        An interesting case report of vertebral artery dissection following polytrauma.
        Int J Surg Case Rep. 2016; 28: 196-199
        • Nolan R
        • Krauss J.
        A case report of vertebral artery dissection following a cervical manipulation.
        Int J Spine Res. 2019; 1: 1-3
        • Nakamura CT
        • Lau JM
        • Polk NO
        • Popper JS.
        Vertebral artery dissection caused by chiropractic manipulation.
        J Vasc Surg. 1991; 14: 122-124
      2. Martin C. Strokes and dissections in BJJ. Accessed June 14, 2021.

      3. Grappling information from BizJitsu. Medium. Accessed June 14, 2021.