Treatment of Vertebral Artery Dissection
For patients with vertebral artery dissection causing ischemic stroke or TIA, initiate antithrombotic therapy immediately for at least 3-6 months using either antiplatelet agents (aspirin or clopidogrel) or anticoagulation (warfarin with target INR 2.0-3.0), as both approaches show equivalent efficacy in preventing recurrent events. 1
Initial Management Algorithm
Step 1: Confirm Diagnosis and Rule Out Contraindications
- Obtain CT angiography of the head and neck with IV contrast as the preferred diagnostic test (100% sensitivity) 2, 3
- Perform concurrent brain imaging (MRI or CT) to assess for ischemic complications, as 50-95% of patients develop cerebral or retinal ischemia 2, 3
- Critical: Rule out intracranial extension with subarachnoid hemorrhage before starting anticoagulation, as this is an absolute contraindication 2, 3
Step 2: Choose Antithrombotic Strategy
The 2021 American Heart Association/American Stroke Association guidelines provide clear direction based on the CADISS trial, which randomized 250 patients and found no significant difference between approaches 1:
Antiplatelet Option:
- Aspirin 81-325 mg daily OR clopidogrel 75 mg daily 2
- Stroke/death rate: 2% at 3 months, 3.2% at 1 year 1
Anticoagulation Option:
- Intravenous heparin followed by warfarin (target INR 2.0-3.0) 2
- Stroke/death rate: 1% at 3 months, 1.6% at 1 year 1
- Observational data suggests lower annual recurrent stroke/TIA/death rate (8.3% vs 12.4% with aspirin) 2, 3
The choice between these two approaches is reasonable and should be based on bleeding risk and patient-specific factors, as the CADISS trial showed no statistically significant difference (OR 0.56,95% CI 0.10-3.21) 1
Step 3: Duration and Transition
- Continue initial antithrombotic therapy for 3-6 months 1, 2
- After this period, transition to long-term antiplatelet therapy regardless of initial treatment choice 2
- Initiate high-intensity statin therapy to reduce LDL cholesterol below 70 mg/dL 3
When Medical Therapy Fails
Reserve endovascular or surgical intervention exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy 1, 2, 3:
- Endovascular options: angioplasty and stenting (Class IIb recommendation) 1, 2
- Surgical options: direct vertebral artery repair or resection with vein graft replacement 2, 3
- These interventions carry significant risks: 5.5% periprocedural neurological complications, 26% restenosis rate at 12 months 1
Common Pitfalls to Avoid
Do not delay treatment waiting for complete diagnostic workup—initiate antithrombotic therapy once diagnosis is confirmed by CTA 3. The mechanism of stroke is artery-to-artery embolism from intraluminal thrombus, making early antithrombotic therapy critical 1.
Do not miss intracranial extension—always obtain brain imaging concurrently with vascular imaging, as anticoagulation can worsen outcomes if subarachnoid hemorrhage is present 2, 3. Intracranial vertebrobasilar dissections carry higher rupture risk 2.
Do not continue invasive workup for asymptomatic lesions that fail to heal anatomically—dissections that do not fully heal are not associated with increased recurrent stroke risk with medical management alone, as anatomic healing occurs in 72-100% of patients 2, 3.
Prognosis and Follow-Up
With appropriate antithrombotic treatment, prognosis is usually favorable 2, 3. Serial non-invasive imaging of the extracranial vertebral arteries is reasonable to assess disease progression 3. Most dissections heal spontaneously, though a subset will develop complications such as pseudoaneurysm formation 1.