What is the management of internal carotid artery (ICA) dissection with stroke symptoms?

Management of Internal Carotid Artery Dissection with Stroke Symptoms

For patients with internal carotid artery (ICA) dissection presenting with stroke symptoms, dual antiplatelet therapy (DAPT) with low-dose aspirin and clopidogrel is recommended for at least 21 days, followed by long-term single antiplatelet therapy with either clopidogrel or aspirin. 1

Initial Assessment and Diagnosis

• Urgent evaluation by a vascular team including a neurologist is essential 1
• Diagnostic imaging should include:
  • Duplex ultrasonography (DUS) as first-line imaging 1
  • Contrast-enhanced CTA or MRA for confirmation 2
  • Fat-saturated T1 MRI of the neck is particularly valuable 1

Antithrombotic Management Algorithm

Acute Phase (First 21 Days)

1. DAPT with low-dose aspirin and clopidogrel (75 mg) is recommended as first-line therapy 1

   • This has a Class I, Level A recommendation for symptomatic carotid stenosis
   • DAPT reduces asymptomatic cerebral embolization and stroke recurrence after TIA/minor stroke

2. Alternative approach: Anticoagulation with heparin followed by warfarin

   • Consider in patients with:
     • Evidence of thrombus in the false lumen
     • Recurrent embolic events despite antiplatelet therapy
     • No intracranial extension of the dissection 2

Maintenance Phase (Beyond 21 Days)

1. Single antiplatelet therapy with either:

   • Clopidogrel 75 mg daily OR
   • Aspirin 81-325 mg daily 1, 2

2. Duration: Long-term therapy is recommended, especially when there is radiographic evidence of residual arterial abnormality 2

Revascularization Considerations

• For most patients: Medical management with antithrombotics is the mainstay of treatment 1
• Revascularization is indicated only for:
  • Persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy 2
  • Symptomatic severe stenosis (70-99%) with documented procedural risk of death/stroke <6% 1
  • If indicated, carotid endarterectomy (CEA) should be performed within 14 days 1

Follow-up Protocol

1. Initial follow-up: DUS within the first month after diagnosis or revascularization 1
2. Long-term monitoring: Annual assessment of:
   • Neurological symptoms
   • Cardiovascular risk factors
   • Treatment adherence 1

Clinical Pearls and Pitfalls

• Most strokes in ICA dissection are embolic rather than hemodynamic in origin, with cortical and large subcortical infarcts predominating 3
• Avoid delaying treatment while waiting for additional imaging if neurological deficits are present 1
• Blood pressure management is important to reduce arterial wall stress while maintaining cerebral perfusion 2
• Recurrence rate of cervical artery dissections is approximately 1% per year 2
• Prognosis is generally favorable with appropriate management, with complete recanalization occurring in approximately 60% of children and high rates in adults 1, 2

The evidence strongly supports antithrombotic therapy as the cornerstone of management for ICA dissection with stroke symptoms, with revascularization reserved for specific scenarios where medical management fails.