What is the treatment for vertebral artery dissection?

Treatment of Vertebral Artery Dissection

The treatment of vertebral artery dissection is primarily conservative, involving anticoagulation with heparin followed by warfarin for 3-6 months, after which antiplatelet therapy may replace anticoagulation once symptoms resolve. 1

Diagnosis

• CT angiography (CTA), MR angiography (MRA), or catheter-based contrast angiography are the preferred diagnostic modalities for vertebral artery dissection (Class I recommendation) 2
• Carotid duplex ultrasonography may identify a dissection flap and differential flow in the true and false lumens, but may miss dissections that begin above the angle of the mandible 1
• Selective catheterization of vertebral arteries may be necessary to delineate collateral filling via the circle of Willis, which guides management 1

Medical Management

Antithrombotic Therapy

• For symptomatic vertebral artery dissection, antithrombotic therapy is recommended for 3-6 months (Class IIa recommendation) 1, 2
• Initial treatment options include:
  • Anticoagulation with intravenous heparin followed by warfarin (target INR 2.0-3.0) 1, 2
  • Low molecular weight heparin followed by warfarin 1
  • Antiplatelet therapy with aspirin (81-325 mg daily) or clopidogrel (75 mg daily) 1, 2
• After the initial 3-6 month period, transition to antiplatelet therapy is recommended 1, 2
• The CADISS trial found no significant difference between antiplatelet and anticoagulant treatments in preventing recurrent stroke in cervical artery dissection (stroke recurrence was rare in both groups) 3

Blood Pressure Management

• The safety and effectiveness of pharmacological therapy with beta-adrenergic antagonists, angiotensin inhibitors, or non-dihydropyridine calcium channel antagonists (verapamil or diltiazem) to lower blood pressure and reduce arterial wall stress are not well established (Class IIb recommendation) 1, 2

Invasive Treatment

• Surgical or endovascular revascularization is reserved for patients with persistent or recurrent symptoms that fail to respond to antithrombotic therapy 1
• Endovascular options include:
  • Angioplasty and stenting may be considered when ischemic neurological symptoms have not responded to antithrombotic therapy (Class IIb recommendation) 1, 2
  • For dominant vertebral artery dissection, stent-assisted reconstruction can restore vessel lumen integrity 4, 5
  • For non-dominant vertebral artery dissection causing emboli, occlusion with coils may be considered 4
• Surgical options (rarely performed) include:
  • Direct vertebral artery repair 1
  • Resection with vein graft replacement 1

Prognosis and Follow-up

• With appropriate antithrombotic treatment, the prognosis is usually favorable 1
• The annual rate of recurrent stroke, TIA, or death was reported as 8.3% in patients treated with anticoagulants versus 12.4% in those treated with aspirin in one observational study 1
• More recent data from the CADISS trial suggests the risk of recurrent stroke is much lower than previously reported in observational studies, with only 2% of patients experiencing recurrent stroke 3

Special Considerations

• Anticoagulation may adversely influence the outcome if subarachnoid hemorrhage occurs due to intracranial extension of the dissection 1
• For patients with bilateral vertebral artery dissections, treatment decisions should be based on the dominance of the affected vessels and presence of embolic complications 4, 5
• A high index of suspicion for vertebral artery dissection should be maintained in younger patients with stroke symptoms, as it accounts for 10-15% of ischemic strokes in patients under 45 years 2, 6