What is the management for a patient with headache, vertebral dissection, and elevated C-Reactive Protein (CRP)?

Management of Vertebral Artery Dissection with Headache and Elevated CRP

Immediate Diagnostic Confirmation

CT angiography (CTA) of the head and neck with IV contrast should be obtained immediately, as it has 100% sensitivity for vertebral artery dissection and is the preferred initial diagnostic modality. 1, 2

• CTA must include imaging from the vertebral artery origin at the aortic arch through to the basilar artery to capture the entire vessel course 2
• MR angiography (MRA) is an alternative but has lower sensitivity (77%) compared to CTA 1, 2
• Brain imaging (MRI or CT) should be performed concurrently to assess for ischemic complications, as 50-95% of patients develop cerebral or retinal ischemia after initial warning symptoms 3, 1

Addressing the Elevated CRP

The elevated CRP in this context requires careful interpretation:

• Elevated CRP with vertebral dissection does NOT automatically indicate large vessel vasculitis - dissection itself can cause inflammatory markers to rise 3
• However, if CRP elevation is unexplained by the dissection and accompanied by constitutional symptoms (weight loss >2 kg, low-grade fever, fatigue, night sweats), urgent referral to a specialist team for vasculitis evaluation is warranted 3
• Giant cell arteritis can present with headache and elevated inflammatory markers, but typically occurs in older patients with temporal headache, jaw claudication, and visual symptoms 3
• Takayasu arteritis should be considered if there are limb claudication symptoms, constitutional symptoms, or the patient is younger 3

Antithrombotic Treatment

Initiate antithrombotic therapy for 3-6 months immediately after diagnosis confirmation. 1, 4

Treatment Options (choose one):

Anticoagulation approach:

• Intravenous heparin or low-molecular-weight heparin initially, followed by warfarin with target INR 2.0-3.0 1, 4
• Observational data suggests 8.3% annual rate of recurrent stroke/TIA/death with anticoagulation versus 12.4% with aspirin alone 1, 4

Antiplatelet approach:

• Aspirin 81-325 mg daily, or clopidogrel 75 mg daily, or extended-release dipyridamole plus aspirin 1, 4
• May be preferred if there is concern for intracranial extension with subarachnoid hemorrhage risk 3, 4

Critical Caveat:

Avoid anticoagulation if there is any evidence of intracranial extension or subarachnoid hemorrhage, as anticoagulation may worsen outcomes in this scenario. 3, 4

Headache-Specific Considerations

The headache pattern in vertebral dissection has characteristic features that aid diagnosis:

• Typically acute onset, persistent, severe, throbbing pain in the occipitonuchal (posterior neck/occipital) region on the side of dissection 5
• Pain often intensified by head flexion and rotation, relieved by head extension and supine positioning 5
• May be accompanied by nausea, vomiting, vertigo, visual disturbances, or syncope 3, 1
• Posterior headache in a young patient should raise immediate suspicion for vertebral dissection, especially if this is the first such headache 6, 7

Monitoring and Follow-up

• After the initial 3-6 month antithrombotic period, transition to long-term antiplatelet therapy 4
• With appropriate treatment, prognosis is usually favorable 1, 4
• Maintain high suspicion in patients under 45 years, as vertebral dissection accounts for 10-15% of ischemic strokes in this age group 4

When to Escalate to Invasive Treatment

Surgical or endovascular revascularization (angioplasty, stenting, or direct repair) is reserved exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy. 3, 4

• This represents treatment failure and requires vascular surgery or interventional neuroradiology consultation 3
• Not indicated for headache alone or stable dissection 4