What is the preferred initial treatment for vertebral artery dissection, anticoagulation or antiplatelet (antiplatelet) therapy?

Management of Vertebral Artery Dissection: Antiplatelet vs. Anticoagulation Therapy

For vertebral artery dissection, either antiplatelet therapy or anticoagulation therapy is appropriate as initial treatment, with antiplatelet therapy generally preferred due to its similar efficacy and better safety profile. 1

Evidence-Based Approach to Treatment Selection

First-Line Treatment Options

• Antiplatelet therapy options:

  • Aspirin (75-325 mg daily)
  • Clopidogrel (75 mg daily)
  • Combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily)

• Anticoagulation therapy options:

  • Initial heparin followed by warfarin (target INR 2.0-3.0)

Treatment Algorithm Based on Current Guidelines

1. For most patients with vertebral artery dissection:

   • Antiplatelet therapy is recommended as first-line treatment 1
   • Duration of treatment typically 3-6 months 1

2. Special considerations for anticoagulation:

   • May be considered in patients with:
     • Evidence of thrombus at the dissection site
     • Recurrent ischemic events despite antiplatelet therapy
     • No contraindications to anticoagulation

Evidence Analysis

The 2023 World Stroke Organization guidelines indicate that for patients with ischemic stroke or TIA and extracranial carotid or vertebral artery dissection, "either antiplatelet therapy or oral anticoagulants are recommended for at least 3 months" 1. This represents the most recent high-quality guideline on the topic.

The CADISS trial (2015-2019), the only randomized controlled trial comparing these treatments, found no significant difference in efficacy between antiplatelet and anticoagulation therapy for cervical artery dissection 2, 3. The recurrent stroke rate was very low in both groups (approximately 2%), contradicting earlier observational studies suggesting higher recurrence rates.

Important Clinical Considerations

• Timing: Treatment should be initiated as soon as possible after diagnosis and exclusion of intracranial hemorrhage 1
• Duration: Treatment typically continues for 3-6 months 1
• Monitoring: Follow-up imaging is reasonable to assess healing of the dissection 1
• Transition: After the acute phase, many patients are transitioned to antiplatelet therapy for long-term management 1

Common Pitfalls to Avoid

1. Delayed diagnosis: Vertebral artery dissection may present with nonspecific symptoms like headache and neck pain before stroke symptoms develop
2. Inadequate imaging: MRA or CTA is recommended rather than ultrasound for evaluation of vertebral arteries 1
3. Misdiagnosis: The CADISS trial found that central review of imaging failed to confirm dissection in approximately 20% of initially diagnosed cases 3
4. Overlooking contraindications: Consider bleeding risk when selecting therapy, particularly with anticoagulation

Conclusion for Clinical Practice

Based on current evidence, both antiplatelet and anticoagulation therapies appear equally effective for preventing recurrent stroke in vertebral artery dissection. Given the similar efficacy and potentially better safety profile, antiplatelet therapy is generally preferred as the initial treatment for most patients with vertebral artery dissection, unless specific factors favor anticoagulation.