From the Guidelines
A vertebral dissection is a serious medical condition where a tear occurs in the inner lining of the vertebral artery, potentially leading to stroke or other severe complications, and requires immediate attention and treatment, usually involving blood thinners and close monitoring 1.
Definition and Causes
A vertebral dissection is characterized by a tear in the inner lining of the vertebral artery, which can cause blood to enter the arterial wall, leading to a separation of the layers and potentially blocking blood flow or forming clots that can travel to the brain. This condition can occur spontaneously or as a result of trauma, sudden neck movements, chiropractic manipulation, or underlying connective tissue disorders such as fibromuscular dysplasia, Ehlers-Danlos syndrome, or Marfan syndrome.
Symptoms and Diagnosis
The symptoms of vertebral dissection can vary, but typically include sudden, severe neck or head pain, often described as the worst headache of one's life. Other symptoms may include dizziness, vision problems, difficulty speaking, weakness on one side of the body, and loss of coordination. The diagnostic algorithm begins with clinical examination and brain imaging, followed by vascular imaging when an ischemic cause is suspected. Carotid duplex ultrasonography, CTA, or MRA may be used to establish the diagnosis of vertebral artery dissection.
Treatment and Management
Treatment for vertebral dissection usually involves conservative management with anticoagulation using heparin followed by warfarin, although the safety and effectiveness of pharmacological therapy to lower blood pressure and reduce arterial wall stress are not well established 1. The prognosis is usually favorable with this approach, but there have been no placebo-controlled trials of anticoagulant or antiplatelet agents or randomized trials comparing anticoagulant and antiplatelet therapy. Further research is needed to evaluate the safety and efficacy of newer antiplatelet agents and to define optimum antithrombotic therapy for patients who experience recurrent cerebral ischemia during antiplatelet therapy 1.
Key Points
- Vertebral dissection is a serious medical condition that requires immediate attention and treatment.
- The condition can occur spontaneously or as a result of trauma, sudden neck movements, chiropractic manipulation, or underlying connective tissue disorders.
- Symptoms include sudden, severe neck or head pain, dizziness, vision problems, difficulty speaking, weakness on one side of the body, and loss of coordination.
- Treatment usually involves conservative management with anticoagulation using heparin followed by warfarin.
- Further research is needed to evaluate the safety and efficacy of newer antiplatelet agents and to define optimum antithrombotic therapy for patients who experience recurrent cerebral ischemia during antiplatelet therapy.
From the Research
Definition and Overview of Vertebral Dissection
- Vertebral artery dissection is a rare pathology that carries a high risk of stroke in a younger population 2.
- It occurs when a tear in the vertebral artery allows blood to enter the wall of the artery and split its layers, resulting in either stenosis or aneurysmal dilatation of the vessel 3.
- Vertebral artery dissection is an important cause of stroke in young and otherwise healthy patients 3.
Causes and Risk Factors
- Vertebral artery dissections may be caused by minor mechanisms, such as a fall or trauma to the neck 2.
- The index of suspicion for vertebral artery dissection should be high, especially in patients with posterior neck pain after a traumatic event 2.
Treatment and Management
- Treatment with anticoagulation or antiplatelets should be initiated if no surgical management is indicated 2.
- Anticoagulation with novel oral anticoagulants (NOACs) may be a reasonable alternative in the management of cervical artery dissection, with similar rates of recurrent stroke and fewer hemorrhagic complications compared to traditional anticoagulants 4.
- The choice of antithrombotic treatment, including antiplatelet agents and anticoagulants, does not appear to significantly affect the rate of new or recurrent events in patients with carotid and vertebral artery dissections 5, 6.
Diagnosis and Clinical Features
- Vertebral artery dissection can be diagnosed using MRI or other imaging modalities 2.
- Clinical features may include posterior neck pain, stroke, or other neurological symptoms 2, 3.
- The natural history and clinical features of vertebral artery dissection are not fully understood and require further study 3.