Vertebral Artery Dissection Treatment & Management

Updated: Feb 21, 2019
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Treatment

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).

Immediate management for dissections leading to acute ischemia includes the initiation of thrombolytic agents provided there are no contraindications to their administration. This therapy is best reserved for patients presenting within 4.5 hours of symptom onset. Beyond this phase, treatment with either anticoagulation or antiplatelet agents are the treatments of choice.

The accepted management of proven or suspected spontaneous VAD consists of antithrombotic therapy (with either antiplatelet or anticoagulant agents) in those patients who are not also affected by the complication of subarachnoid hemorrhage. [13, 39] 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.

Data guiding this management strategy comes from the 2015 Cervical Artery Dissection in Stroke Study (CADISS) trial discussed in the Medical Care section. [40] The pathophysiologic mechanism underlying VAD includes hemorrhage into the arterial wall and subarachnoid hemorrhage as a devastating complication of the condition.

Consultations

Consult with a neurosurgeon.

Hospitalization

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.

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Medical Care

Findings from the Cervical Artery Dissection in Stroke Study (CADISS) trial, the only randomized trial to examine antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) were published in 2015, in which no differences in outcomes between groups receiving antiplatelets versus anticoagulants were found. [40] Two hundred and fifty patients (118 with carotid artery dissection [CAD]; 132 with VAD) were randomized to either antiplatelet therapy or anticoagulant therapy and followed out to a 3 month period. Recurrent stroke was rare within this time frame (2%). [40] There was a very low incidence of postdissection adverse effects in both groups, meaning randomized studies examining treatment effects on secondary outcomes will be lacking.

Similar findings to those discussed above have been reported in previous meta-analyses examining antithrombotic treatments for CAD and VADs. [41, 42]

At this time, therefore, it would be reasonable to treat patients who are not candidates for surgical therapy, to receive either antiplatelet therapy (aspirin, with or without clopidogrel) or anticoagulant therapy (warfarin, with or without heparin).

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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. [43] 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. Surgical or endovascular repair of dissections is best reserved for patients who experience recurrent ischemic episodes despite antithrombotic therapy. It may also have a role for patients with intracranial dissections who present with subarachnoid hemorrhage. [44]

A 2014 meta-analysis of vertebral artery dissections (VADs) treated endovascularly found that 86.3% of procedures were associated with good or excellent outcomes. [45] 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. [45]

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. [46]

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Long-Term Monitoring

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.

Other considerations

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.

Therapy recommendations for patients with stroke and arterial dissection are available from the American Heart Association/American Stroke Association. [47, 48]

For patient education resources, see the Brain and Nervous System Center, as well as Stroke.

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