Does the management of large vessel occlusion (LVO) due to vertebral artery dissection differ from standard LVO care?

Management of Large Vessel Occlusion Due to Vertebral Artery Dissection

The core principles of LVO management remain the same for vertebral artery dissection, but you must add anticoagulation for at least 3 months regardless of whether thrombolytic therapy is used, and you should have a lower threshold for endovascular intervention given the dual pathology of dissection plus thrombosis. 1

Key Differences from Standard LVO Care

Anticoagulation is Mandatory

• Initiate anticoagulation with intravenous heparin followed by oral warfarin for at least 3 months in all patients with vertebral artery dissection causing acute ischemic stroke, regardless of whether you use thrombolytic therapy. 1
• This differs fundamentally from standard atherosclerotic LVO where antiplatelet therapy is the norm—dissection creates a substrate for ongoing thromboembolic events that requires anticoagulation. 1, 2
• The dissection itself can propagate and serve as an ongoing embolic source even after initial recanalization. 2

Imaging Must Identify the Dissection

• Standard LVO imaging (NCCT + CTA) is still your first step to rule out hemorrhage and confirm vessel occlusion. 1
• However, catheter-based contrast angiography is typically required before revascularization for vertebral artery dissection because neither MRA nor CTA reliably delineates the vertebral artery origins and dissection characteristics. 1
• Look specifically for the "string sign," pseudoaneurysm formation, or intimal flap on angiography—these findings confirm dissection and influence your treatment strategy. 2, 3

Treatment Algorithm

Within 0-6 Hours

• Proceed with standard LVO protocol: IV alteplase (0.9 mg/kg, max 90 mg) if within 4.5 hours AND immediate preparation for mechanical thrombectomy. 1, 4
• Do not delay thrombectomy for dissection—the time-dependent nature of stroke outcomes (8-14% decrease in good outcome per 30-minute delay) takes precedence. 1, 5
• Start anticoagulation immediately after excluding hemorrhagic transformation, even if you used thrombolytics. 1

Endovascular Approach Considerations

• Use the BADDASS technique (balloon guide with large bore distal access catheter with dual aspiration with stent-retriever) as your standard approach for mechanical thrombectomy. 1
• Consider stent-assisted reconstruction of the vertebral artery if the dissection is causing hemodynamically significant stenosis or recurrent embolization—this restores vessel lumen integrity immediately and is safe in selected cases. 2, 6
• If the dissected vertebral artery is proven to be the embolic source and the contralateral vertebral artery is dominant, consider coil occlusion of the pathological vessel to prevent further emboli. 2
• Deploy self-expanding intracranial stents from the patent vessel through the dissection if needed to achieve recanalization (TIMI 3 flow). 6

Posterior Circulation Specific Considerations

• For basilar artery occlusion secondary to vertebral dissection with NIHSS ≥6 and PC-ASPECTS ≥6, thrombectomy is indicated within 12 hours (Class I, Level B-R) and reasonable up to 24 hours (Class IIa, Level B-R). 1
• Even with large brainstem infarctions on DWI, aggressive recanalization should be considered—recovery from "locked-in" syndrome to ambulation is possible with successful reperfusion. 6

Critical Pitfalls to Avoid

Don't Withhold Anticoagulation Due to Thrombolytic Use

• The traditional concern about combining anticoagulation with thrombolytics is outweighed by the risk of dissection propagation and recurrent embolization in vertebral artery dissection. 1
• Monitor closely for hemorrhagic transformation, but anticoagulation is recommended regardless of initial thrombolytic therapy. 1

Don't Assume Anticoagulation Alone is Sufficient

• Anticoagulation may be ineffective to prevent symptom progression or dissection extension in acute presentations. 2
• If the patient has ongoing symptoms despite anticoagulation or develops a pseudoaneurysm, endovascular intervention (stenting or coiling) should be considered immediately. 2, 7

Don't Delay for Perfect Imaging

• While catheter angiography provides the best dissection characterization, don't delay thrombectomy to obtain it if CTA already confirms LVO. 1
• Obtain detailed angiographic assessment during the thrombectomy procedure itself. 1

Post-Intervention Management

Blood Pressure Management

• Maintain BP <185/110 mmHg if anticoagulation is initiated, using labetalol, nicardipine, or clevidipine. 4
• This is more stringent than non-anticoagulated patients where you tolerate BP up to 220/120 mmHg. 4

Duration of Anticoagulation

• Continue anticoagulation for at least 3 months, then reassess with repeat vascular imaging. 1
• Transition to antiplatelet therapy only after documented healing of the dissection. 1