What is the treatment for vertebral artery dissection?

Treatment of Vertebral Artery Dissection

For symptomatic vertebral artery dissection, initiate antithrombotic therapy for 3-6 months using either anticoagulation (heparin followed by warfarin with INR 2.0-3.0) or antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily), as both approaches have equivalent efficacy in preventing recurrent stroke. 1

Initial Antithrombotic Management

The cornerstone of treatment is antithrombotic therapy, with two equally acceptable options:

Option 1: Anticoagulation

• Start intravenous heparin followed by warfarin (target INR 2.0-3.0) 1
• Continue for 3-6 months 1
• Risk of hemorrhagic transformation appears low (<5%) 2

Option 2: Antiplatelet Therapy

• Aspirin 81-325 mg daily OR clopidogrel 75 mg daily 1
• Continue for 3-6 months 1

Evidence Supporting Equivalence

The landmark CADISS trial (2015) definitively showed no difference between antiplatelet and anticoagulation strategies, with stroke recurrence occurring in only 2% of patients overall (3% antiplatelet vs 1% anticoagulation, p=0.63) 3. This finding is reinforced by observational data showing recurrent ischemic events are rare regardless of treatment choice 4. The actual risk of recurrent stroke is much lower than historically reported (1-4% over 2-5 years), making either treatment approach reasonable. 2, 1

Critical Caveat: Intracranial Extension

Anticoagulation is contraindicated if subarachnoid hemorrhage occurs from intracranial extension of the dissection. 2, 5 Intracranial vertebrobasilar dissections carry higher rupture risk 2. Carefully review imaging to exclude intracranial involvement before initiating anticoagulation.

Long-Term Management After Initial 3-6 Months

• Transition to antiplatelet therapy (aspirin or clopidogrel) for ongoing secondary stroke prevention 1
• Add statin therapy to reduce LDL cholesterol below 100 mg/dL (Class I recommendation), or ideally below 70 mg/dL for patients who sustained stroke (Class IIa recommendation) 5
• Implement lifestyle modifications including smoking cessation 5

Blood Pressure Management

The role of specific antihypertensive agents (beta-blockers, ACE inhibitors, or non-dihydropyridine calcium channel blockers) to reduce arterial wall stress is not well established (Class IIb recommendation) 1, 5. However, general blood pressure control remains important.

Endovascular or Surgical Intervention

Reserve invasive treatment for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy. 1, 5

• Endovascular options include angioplasty and stenting (Class IIb recommendation) 1, 6
• Surgical options include direct repair or vein graft replacement 1
• These interventions are rarely needed, as anatomic healing occurs in 72-100% of patients with medical management alone 2

Diagnostic Considerations

Use CT angiography, MR angiography, or catheter-based angiography for diagnosis (Class I recommendation) 1. Carotid duplex ultrasonography may miss dissections above the mandible angle 1. Maintain high clinical suspicion in younger patients with stroke symptoms, as vertebral artery dissection accounts for 10-15% of strokes in patients under 45 years. 1

Prognosis

With appropriate antithrombotic treatment, prognosis is usually favorable 1, 5. Dissections that do not fully heal anatomically are not associated with increased recurrent stroke risk, so further intervention for asymptomatic lesions is not warranted 2.