eMedicine Specialties > Emergency Medicine > Cardiovascular

Dissection, Vertebral Artery: Follow-up

Author: Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Coauthor(s): Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Contributor Information and Disclosures

Updated: Aug 5, 2009

Follow-up

Further Inpatient Care

  • Patients with VAD warrant admission and close neurologic monitoring until anticoagulation with warfarin is complete and patient's clinical condition is stable.
  • Transcranial Doppler may be used to monitor the intracranial vertebral artery both for patency and for the abnormal flow associated with embolic phenomena.

Further Outpatient Care

  • Medications
    • No clear guidelines exist on the duration of anticoagulation in patients with VAD. Consider treatment regimens of 3-6 months or until radiographic resolution is established by either MRI or follow-up angiography.
    • Rarely, patients experience reocclusion when removed from anticoagulant therapy, which subjects them to longer regimens.
  • Most authors support follow-up imaging at 3 months after diagnosis, preferably with a noninvasive technique such as MRI.
  • As with all patients on warfarin therapy, monitor INR at regular intervals.

Complications

  • Brainstem infarction
  • Cerebellar infarction
  • Subarachnoid hemorrhage
  • Vertebral artery pseudoaneurysm causing compressive cranial neuropathy

Prognosis

  • Extracranial dissection
    • Most patients do remarkably well if they survive the initial crisis. As many as 88% of these patients demonstrate a complete clinical recovery at follow-up. However, this suggests an overall risk of death, recurrent transient ischemic attacks, or stroke of approximately 10%
    • One series suggests that the severity of neurologic deficits at the time of presentation is related directly to the functional outcome.
    • Follow-up angiography demonstrates spontaneous healing in as many as two thirds of these patients.
  • Intracranial dissection
    • Patients with intracranial vertebrobasilar dissection constitute a more severely affected subgroup of all patients with VAD.19
    • The presentation of a dissection involving the intracranial portion of the vertebral artery (segment IV) is characterized by rapidly progressive neurologic deficits, including depressed consciousness.
    • VAD is associated with subarachnoid hemorrhage, brainstem infarctions, and high mortality rate.19

Patient Education

  • For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Stroke.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider diagnosis of VAD. The routine ED evaluation of headache (CT scan and LP) fails to identify patients with VAD. Most patients are evaluated by one other physician before the diagnosis of VAD is established.
  • Failure to differentiate between the pain associated with VAD and musculoskeletal pain in the absence of a significant mechanism of injury
  • Failure to consider occipital headache as a sign of VAD. Occipital headache lacks features that traditionally indicate a serious etiology. Headaches associated with VAD lack a thunderclap onset, are not associated with meningismus or fever, and are not associated with a history of significant head trauma.
  • Failure to consider etiologies of the stroke syndrome, other than atherosclerosis, if the patient presents with brainstem or cerebellar dysfunction. This is especially true in the context of a negative CT scan and/or LP.
 


More on Dissection, Vertebral Artery

Overview: Dissection, Vertebral Artery
Differential Diagnoses & Workup: Dissection, Vertebral Artery
Treatment & Medication: Dissection, Vertebral Artery
Follow-up: Dissection, Vertebral Artery
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection: time for a therapeutic trial?. Stroke. Dec 2003;34(12):2856-60. [Medline]. [Full Text].

  2. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. Jul 11 2000;163(1):38-40. [Medline].

  3. Rubinstein SM, Peerdeman SM, van Tulder MW. A systematic review of the risk factors for cervical artery dissection. Stroke. Jul 2005;36(7):1575-80. [Medline].

  4. Stahmer SA, Raps EC, Mines DI. Carotid and vertebral artery dissections. Emerg Med Clin North Am. Aug 1997;15(3):677-98. [Medline].

  5. Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. Nov 2000;27(4):292-6. [Medline].

  6. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. Aug 1995;45(8):1517-22. [Medline].

  7. Garry D, Forrest-Hay A. A headache not to be sneezed at. Emerg Med J. May 2009;26(5):384-5. [Medline].

  8. Raupp SF, Jellema K, Sluzewski M. Sudden unilateral deafness due to a right vertebral artery dissection. Neurology. Apr 27 2004;62(8):1442. [Medline].

  9. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. Oct 2003;250(10):1179-84. [Medline].

  10. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. Aug 2002;249(8):1098-104. [Medline].

  11. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. May 13 2003;60(9):1424-8. [Medline].

  12. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J R Soc Med. Mar 2001;94(3):107-10. [Medline].

  13. Pezzini A, Caso V, Zanferrari C. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry. Jan 2006;77(1):95-7. [Medline].

  14. Grau AJ, Brandt T, Buggle F. Association of cervical artery dissection with recent infection. Arch Neurol. Jul 1999;56(7):851-6. [Medline].

  15. Levy C, Laissy JP, Raveau V, et al. Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology. Jan 1994;190(1):97-103. [Medline].

  16. Yoshimoto Y, Wakai S. Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings. Stroke. Feb 1997;28(2):370-4. [Medline]. [Full Text].

  17. Prabhu V, Kizer J, Patil A, et al. Vertebrobasilar thrombosis associated with nonpenetrating cervical spine trauma. J Trauma. Jan 1996;40(1):130-7. [Medline].

  18. Ramphul N, Geary U. Caveats in the management and diagnosis of cerebellar infarct and vertebral artery dissection. Emerg Med J. Apr 2009;26(4):303-4. [Medline].

  19. de Bray JM, Penisson-Besnier I, Dubas F, Emile J. Extracranial and intracranial vertebrobasilar dissections: diagnosis and prognosis. J Neurol Neurosurg Psychiatry. Jul 1997;63(1):46-51. [Medline].

  20. Caplan LR. Vertebrobasilar occlusive disease. In: Barnett H, ed. Stroke: Pathophysiology, Diagnosis and Management. Vol 1. London, England: Churchill Livingstone; 1986:549-619.

  21. De Giorgio F, Vetrugno G, De Mercurio D, et al. Dissection of the vertebral artery during a basketball game: a case report. Med Sci Law. Jan 2004;44(1):80-6. [Medline].

  22. Hamada J, Kai Y, Morioka M, et al. Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage. J Neurosurg. Dec 2003;99(6):960-6. [Medline].

  23. Mokri B. Traumatic and spontaneous extracranial internal carotid artery dissections. J Neurol. Oct 1990;237:356-61. [Medline].

  24. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. Mar 22 2001;344(12):898-906. [Medline].

  25. Sturzenegger M, Mattle HP, Rivoir A, et al. Ultrasound findings in spontaneous extracranial vertebral artery dissection. Stroke. Dec 1993;24(12):1910-21. [Medline].

[ CLOSE WINDOW ]

Keywords

VAD, vertebral artery dissection, stroke, aneurysm, arteria vertebralis, hematoma, carotid artery dissection, CAD, stroke rehabilitation

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Royal College of Physicians and Surgeons of Canada, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.