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Vertebral Artery Dissection Treatment & Management

  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Nov 07, 2015

Emergency Department Care

Patients who demonstrate significant neurologic deficits merit transport to stroke centers or other health care institutions able to offer appropriate care of either spontaneous or traumatic vertebral artery dissection (VAD).

Once contraindications to anticoagulation have been ruled out, the accepted management of proven or suspected spontaneous VAD consists of anticoagulant therapy in those patients who are not also affected by the complication of subarachnoid hemorrhage.[13]  This approach is intended to prevent thrombogenic or embolic occlusion of the vertebrobasilar network and subsequent infarction of posterior CNS structures, brain stem, and cerebellum.

This management strategy is adhered to despite the fact that no randomized controlled studies support this approach.[34]  Furthermore, the pathophysiologic mechanism underlying VAD includes hemorrhage into the arterial wall and subarachnoid hemorrhage as a devastating complication of the condition.

Evidence in favor of anticoagulation is suggested by a number of published series that demonstrate an encouraging prognosis for those patients who survive their initial presentation and subsequently undergo anticoagulation.[1]  Most of these patients underwent head CT to exclude frank subarachnoid hemorrhage before beginning anticoagulant therapy. Anticoagulation therapy is further supported by the fact that no published cases have documented brainstem hemorrhage or clinical deterioration as a result of this therapy. Recent studies suggest that treatment with novel anticoagulants may yield outcomes and safety profiles similar to therapy with conventional vitamin K antagonists.[35]

Antiplatelet therapy is a reasonable option to consider in patients who are suspected of suffering from a VAD while awaiting definitive investigations.


Consult with a neurosurgeon.


Patients with vertebral artery dissection (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.


Surgical Care

New technological advancements in endovascular procedures indicate the growing popularity of endovascular recanalization of dissections. These procedures are viable, effective, and tolerable treatment alternatives with impressive radiographic results.[36] However, endovascular treatments are controversial, as most of the related mortality and morbidity is secondary to emboli formation in the vessel, which is amenable to antiplatelet or anticoagulation therapy. Furthermore, most dissections heal spontaneously.

A 2014 meta-analysis of vertebral artery dissections (VADs) treated endovascularly found that 86.3% of procedures were associated with good or excellent outcomes.[37] Postoperative complications occurred in 10.5% (complications included vasospasm, postoperative rebleeding, and ischemia) with an overall mortality of 8.7%. The authors suggested that reduced operating time, minimal invasiveness, and comparative safety make endovascular procedures suitable options for intervention-amenable dissections.[37]

Surgical treatment is reserved for those patients in whom symptoms are persistent and refractory to maximal medical therapy and who are not candidates for endovascular procedures. Surgical options for vertebral artery dissections include in situ interposition grafting or extracranial-intracranial bypasses.[38]

Contributor Information and Disclosures

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.


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 is a member of the following medical societies: American College of Emergency Physicians, Royal College of Physicians and Surgeons of Canada, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Inderjeet Singh Sahota, MSc Research Assistant, Emergency Medicine and Cardiology and Medical Student, Cumming School of Medicine, University of Calgary

Inderjeet Singh Sahota, MSc is a member of the following medical societies: Canadian Medical Association, Canadian Cardiovascular Society, Heart Rhythm Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, 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.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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 Association for Physician Leadership, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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A, Dissection of the left vertebral artery secondary to guidewire injury. B, Complete resolution occurred in 6 months with only aspirin and clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, Bridgewater, NJ) therapy.
Gunshot wound to the right side of the neck. A, The angiogram shows transections of the right vertebral artery (RVA) and the right internal maxillary artery (RIMAX), with partial transection and pseudoaneurysm formation of the midcervical right internal carotid artery (RICA). The transected segments of the RVA and RIMAX were embolized with coils. B and C, The RICA pseudoaneurysm was successfully treated with a 7 x 40-mm covered stent (Wallgraft; Boston Scientific Corp, Natick, Mass).
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