Vertebral Artery Dissection Medication

Updated: Jan 18, 2017
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Medication

Medication Summary

Anticoagulant and antiplatelet agents are the drugs of choice (DOCs) to prevent thromboembolic disorders associated with vertebral artery dissection (VAD). More potent agents (eg, intra-arterial thrombolytics) have also been described in treating selective cases.

In a randomized controlled trial of 250 patients with vertebral artery (n = 132) or extracranial carotid (n = 118) dissections who were randomly assigned to antiplatelet therapy versus anticoagulation therapy within 7 days of symptom onset, the investigators found no difference between either agent in preventing stroke and death after 3 months. [27] Indeed, there were only 4 strokes in the entire cohort and no deaths, far lower than reported in other observational studies. [27] These results were similar to a previous meta-analysis. [28]

Studies in recent years suggest that novel oral anticoagulants (NOACs) such as dabigatran, rivaroxaban, and apixaban may be viable alternatives with similar efficacy and safety outcomes to vitamin K antagonists. [49]  NOACs may be associated with similar rates of stroke at follow-up, but they have fewer hemorrhagic complications. [50] Nonetheless, further research is required.

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Anticoagulants, Cardiovascular

Class Summary

These agents are indicated in patients with VAD to prevent recurrent or ongoing thromboembolic occlusion of vertebrobasilar circulation.

Heparin

Potentiates antithrombin III activity. Does not actively lyse, but blocks further thrombogenesis. Prevents reaccumulation of a clot after spontaneous fibrinolysis. aPTT value 1.5-2 times control (50-80 s) is considered therapeutic.

Warfarin (Coumadin)

For prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Interferes with hepatic vitamin K-dependent carboxylation. Usually prolongs PT in 48 h.

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Antiplatelet Agents, Cardiovascular

Class Summary

Antiplatelet agents have been used effectively in treating VAD but are reserved for those patients who cannot tolerate or have contraindications to anticoagulants.

Aspirin (Zorprin, Bayer Buffered Aspirin)

Inhibits cyclooxygenase, which produces thromboxane A2, a potent platelet activator.

Ticlopidine (Ticlid)

Second-line antiplatelet therapy for patients who are intolerant to aspirin or in whom aspirin therapy fails.

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Thrombolytics

Class Summary

Lysis of the occluding embolus may be considered by localized intra-arterial injection of alteplase (ie, tissue plasminogen activator [TPA]).

Alteplase (Activase, TPA)

Tissue plasminogen activator exerts effect on fibrinolytic system to convert plasminogen to plasmin. Plasmin degrades fibrin, fibrinogen, and procoagulant factors V and VIII Serum half-life is 4-6 min but half-life lengthened when bound to fibrin in clot.

Intra-arterial dose: 0.3 mg/kg; not to exceed 10-20 mg

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