What are the symptoms and treatment options for vertebral artery dissection?

Vertebral Artery Dissection: Symptoms and Treatment

Clinical Presentation

Vertebral artery dissection typically presents with headache (51%), neck pain (46%), and dizziness/vertigo (58%), often progressing to posterior circulation stroke in approximately two-thirds of patients. 1, 2

Primary Symptoms

• Headache and neck pain are the most characteristic initial symptoms, typically presenting as acute onset, persistent, severe, throbbing pain in the occipitonuchal region 1
• Dizziness and vertigo occur in 58% of patients and may be accompanied by nausea, vomiting, visual disturbances, or syncope 3, 1, 2
• Neurological deficits develop after initial warning symptoms in 50-95% of cases, including cerebral or retinal ischemia 3, 1
• Horner syndrome may occur with carotid dissection but is less common with vertebral dissection 3

Critical Warning Signs

• Sudden catastrophic neurological events can occur, though most patients have a more gradual onset with warning symptoms 1
• Limb ataxia and cognitive disturbances may develop rapidly, even in patients initially presenting with only nonspecific musculoskeletal complaints 4
• Visual disturbances including diplopia or visual field defects indicate posterior circulation involvement 3, 1

Common Pitfall

Many patients present with nonspecific neck pain and headache without obvious neurological symptoms initially, which can lead to misdiagnosis. A high index of suspicion is essential in younger patients (under 45 years) with craniocervical pain, as vertebral artery dissection accounts for 10-15% of ischemic strokes in this age group 5, 6, 4

Risk Factors and Triggers

• Sudden or excessive neck movement (hyperflexion/hyperextension) is a primary risk factor 1
• Minor trauma including chiropractic manipulation, falls, or abnormal posturing can precipitate dissection 1, 7
• Fibromuscular dysplasia is associated with approximately 15% of cases 3, 1
• Fewer than half of patients have obvious trauma history, and only 7.9% have known connective tissue disease 2

Diagnostic Approach

CT angiography (CTA) of the head and neck with IV contrast is the preferred initial diagnostic modality with 100% sensitivity for vertebral artery dissection. 3, 1

Imaging Hierarchy

• CTA head and neck with IV contrast has the highest reported sensitivity (100%) compared to conventional angiography and should include the entire vessel from aortic arch to basilar artery 3, 1
• MR angiography (MRA) has approximately 77% sensitivity and is an acceptable alternative, particularly when combined with vessel wall imaging sequences 3, 1
• Brain MRI or CT should be performed concurrently to assess for ischemic complications, as 50-95% develop cerebral ischemia 1
• Carotid duplex ultrasonography has only 71% sensitivity and may miss dissections above the angle of the mandible 3, 5

Treatment Algorithm

Immediate Medical Management (First-Line)

Antithrombotic therapy for 3-6 months is recommended immediately after diagnosis confirmation (Class IIa recommendation). 1, 5

Option 1: Anticoagulation

• Intravenous heparin followed by warfarin (target INR 2.0-3.0) 1, 5
• Low-molecular-weight heparin is an alternative to unfractionated heparin 3
• Annual recurrent stroke/TIA/death rate: 8.3% with anticoagulation 1, 5

Option 2: Antiplatelet Therapy

• Aspirin 81-325 mg daily 5
• Clopidogrel 75 mg daily 5
• Extended-release dipyridamole plus aspirin combination 3
• Annual recurrent stroke/TIA/death rate: 12.4% with aspirin 1, 5

Critical Contraindication

Anticoagulation is absolutely contraindicated if subarachnoid hemorrhage occurs from intracranial extension of the dissection, as intracranial vertebrobasilar dissections carry higher rupture risk 5, 8

Long-Term Management (After 3-6 Months)

• Transition to antiplatelet therapy after the initial 3-6 month antithrombotic period 5
• Statin therapy to reduce LDL cholesterol below 70 mg/dL is reasonable (Class IIa recommendation) for all patients who have sustained ischemic stroke 8
• Blood pressure control may be beneficial, though specific pharmacological approaches are not well established (Class IIb recommendation) 5, 8

Invasive Treatment (Reserved for Treatment Failures)

Surgical or endovascular revascularization is reserved exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy. 1, 5

• Endovascular angioplasty and stenting may be considered when symptoms persist (Class IIb recommendation) 5
• Surgical options include direct vertebral artery repair or resection with vein graft replacement 5

Prognosis

• Good outcome (modified Rankin scale 0-1) occurs in 67% of patients with appropriate treatment 2
• Anatomic healing occurs in 72-100% of patients with medical management alone 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 5
• Poor outcome (modified Rankin scale 5-6) occurs in 10% of patients 2

Follow-Up Monitoring

• Serial non-invasive imaging of the extracranial vertebral arteries is reasonable to assess disease progression (Class IIa recommendation) 8
• Risk of hemorrhagic transformation appears low (<5%) in patients treated with antithrombotic therapy 5