What is the management approach for vertebral artery dissection?

From the Guidelines

The management of vertebral artery dissection primarily involves anticoagulation or antiplatelet therapy to prevent stroke, with careful monitoring and supportive care. Initial treatment typically begins with either heparin (followed by warfarin with target INR 2-3) or antiplatelet agents like aspirin (81-325 mg daily) or clopidogrel (75 mg daily) 1. Treatment duration is typically 3-6 months, during which the dissection usually heals. Choice between anticoagulation and antiplatelet therapy depends on patient-specific factors, with antiplatelet therapy often preferred in cases without significant stroke or with subarachnoid hemorrhage risk. Pain management with analgesics is important, as neck pain is a common symptom. Blood pressure control is essential, typically maintaining systolic pressure below 140 mmHg with medications like labetalol or nicardipine if needed. Some key points to consider in management include:

• Antithrombotic treatment with either an anticoagulant or a platelet inhibitor for at least 3 to 6 months is reasonable for patients with extracranial carotid or vertebral arterial dissection associated with ischemic stroke or TIA 1.
• The relative efficacy of antiplatelet therapy compared with anticoagulation is unknown for patients with ischemic stroke or TIA and extracranial carotid or vertebral arterial dissection 1.
• Endovascular therapy, particularly stent placement, is emerging as an increasingly popular option to treat dissections 1. Surgical or endovascular interventions are reserved for cases with progressive neurological deficits despite medical therapy, recurrent ischemia, or expanding pseudoaneurysms. Follow-up imaging at 3-6 months is recommended to assess healing 1. The rationale for antithrombotic therapy is to prevent thrombus formation at the dissection site that could lead to embolism and subsequent stroke, which is the primary complication of vertebral artery dissection. It's also important to note that the goals of therapy when treating patients with dissections and ischemic stroke are to prevent further ischemic strokes and to promote healing of the dissected vessel 1. Overall, the management approach should be individualized based on patient risk factor profiles, tolerance, and other clinical characteristics.

From the Research

Vertebral Artery Dissection Management

The management of vertebral artery dissection involves various approaches, including medical treatment and endovascular interventions.

• Anticoagulation with intravenous heparin followed by oral warfarin has been recommended for all patients with acute dissections, unless there are contra-indications 2, 3.
• Antiplatelet treatment is also considered as an alternative to anticoagulation, with similar rates of new or recurrent ischemic and hemorrhagic events 4.
• Endovascular treatment, such as stent-assisted angioplasty, has been shown to be a safe and effective method for restoring vessel lumen integrity in selected cases of vertebral artery dissection 2, 3.
• The choice of treatment depends on the individual patient's condition, including the location and severity of the dissection, as well as the presence of any contra-indications to anticoagulation or antiplatelet therapy.

Medical Treatment

Medical treatment for vertebral artery dissection typically involves anticoagulation or antiplatelet therapy.

• Anticoagulation with heparin and warfarin has been shown to be effective in preventing further strokes caused by the dissection 5.
• Antiplatelet treatment, such as aspirin, is also considered as an alternative to anticoagulation, with similar rates of new or recurrent ischemic and hemorrhagic events 4, 6.
• The duration of anticoagulation or antiplatelet therapy is not well established, but it is typically continued for several months to a year or more, depending on the individual patient's condition.

Endovascular Treatment

Endovascular treatment, such as stent-assisted angioplasty, is considered for patients with vertebral artery dissection who have failed medical treatment or have contra-indications to anticoagulation or antiplatelet therapy.

• Stent-assisted angioplasty has been shown to be a safe and effective method for restoring vessel lumen integrity in selected cases of vertebral artery dissection 2, 3.
• The use of emboli protection devices during endovascular treatment can help prevent thromboembolic complications 2.
• The choice of endovascular treatment depends on the individual patient's condition, including the location and severity of the dissection, as well as the presence of any contra-indications to anticoagulation or antiplatelet therapy.