What is the treatment for a cerebrovascular accident (CVA) secondary to vertebral artery dissection?

Treatment of CVA Secondary to Vertebral Artery Dissection

For acute ischemic stroke from vertebral artery dissection, initiate antithrombotic therapy immediately for at least 3-6 months using either anticoagulation (heparin followed by warfarin, INR 2.0-3.0) or antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily), as both approaches show equivalent efficacy with stroke/death rates of 1-2% at 3 months. 1

Acute Phase Management (First 24 Hours)

Thrombolysis Eligibility

• Vertebral artery dissection is NOT a contraindication to IV thrombolysis if the patient meets standard eligibility criteria for acute ischemic stroke 2, 3
• Administer recombinant tissue plasminogen activator within the standard 4.5-hour window if no other contraindications exist 3

Mechanical Thrombectomy Consideration

• Perform mechanical thrombectomy within 12 hours if NIHSS ≥6, PC-ASPECTS ≥6, and age 18-89 years 4
• Thrombectomy remains reasonable between 12-24 hours from last known well using the same criteria 4

Critical Imaging Before Treatment

• Obtain CT angiography (CTA) or MR angiography (MRA) immediately, which have 94% sensitivity and 95% specificity for vertebral artery pathology 4
• Perform concurrent brain imaging (MRI or CT) to exclude intracranial extension with subarachnoid hemorrhage before initiating anticoagulation, as this is an absolute contraindication 1, 5

Medical Management Algorithm

Initial Antithrombotic Choice (3-6 Months)

Option 1: Anticoagulation (Preferred for extracranial dissection with thrombus)

• Start IV heparin immediately, then transition to warfarin (target INR 2.0-3.0) 6, 1
• This approach yields 1% stroke/death rate at 3 months and 1.6% at 1 year 1
• Annual recurrent stroke/TIA/death rate of 8.3% with anticoagulation versus 12.4% with aspirin alone 1, 5

Option 2: Antiplatelet Therapy (Alternative based on bleeding risk)

• Aspirin 81-325 mg daily OR clopidogrel 75 mg daily 1
• Results in 2% stroke/death rate at 3 months and 3.2% at 1 year 1
• The CADISS trial showed no statistically significant difference between approaches (OR 0.56,95% CI 0.10-3.21) 1

Enhanced Antiplatelet Regimens

• Aspirin plus extended-release dipyridamole (200 mg twice daily) reduced vertebrobasilar territory stroke/TIA from 10.8% to 5.7% compared to placebo 6, 4
• Ticlopidine 250 mg twice daily was superior to aspirin alone for secondary prevention in posterior circulation disease 6, 4

Long-Term Management (After 3-6 Months)

• Transition to indefinite antiplatelet therapy regardless of initial treatment choice 1, 5
• Initiate high-intensity statin therapy to reduce LDL cholesterol below 70 mg/dL 5
• Continue aggressive cardiovascular risk factor modification 4

Endovascular/Surgical Intervention

Indications (Highly Selective)

• Reserve revascularization exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy 4, 1, 5
• Endovascular options include angioplasty and stenting 1, 5
• Surgical options include direct vertebral artery repair or resection with vein graft replacement 1, 5

Risks of Intervention

• Endovascular treatment carries 0.3% death risk, 5.5% periprocedural neurological complication risk, and 0.7% posterior stroke risk at 14.2 months 4, 1
• Restenosis occurs in 26% of cases at 12-month follow-up, though not consistently correlated with recurrent symptoms 4, 1
• For distal vertebrobasilar disease, neurological complications develop in 24%, approaching 80% in urgent revascularization cases 6

Special Clinical Scenarios

Intracranial Extension with Subarachnoid Hemorrhage

• Anticoagulation is absolutely contraindicated if subarachnoid hemorrhage occurs from intracranial extension, as intracranial vertebrobasilar dissections carry higher rupture risk 1, 2
• Antiplatelet agents should also be avoided in this setting 2
• Endovascular treatment becomes first-line for ruptured intracranial vertebral artery dissecting aneurysms 7

Traumatic Vertebral Artery Dissection

• Initiate antithrombotic therapy immediately for at least 3-6 months with either anticoagulation or antiplatelet therapy 5
• Anatomic healing occurs in 72-100% of dissection cases with appropriate medical management 4, 1, 5

Follow-Up and Monitoring

Imaging Surveillance

• Serial noninvasive imaging (CTA or MRA) of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization 4, 5
• Follow-up imaging at 3 months typically shows complete vascular healing in most cases 3

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 1
• The risk of hemorrhagic transformation appears low (<5%) in patients with vertebral artery dissection 1

Critical Pitfalls to Avoid

• Do not use dual antiplatelet therapy (aspirin + clopidogrel) routinely—hemorrhage risk outweighs benefit 4
• Do not delay antithrombotic therapy waiting for "complete" diagnostic workup—initiate treatment once diagnosis is confirmed by CTA 5
• Do not miss intracranial extension before starting anticoagulation—always obtain brain imaging concurrently 1, 5
• Do not pursue revascularization as first-line therapy—insufficient evidence of benefit over medical management exists 4, 1
• Do not attribute all neck pain after trauma or manipulation to musculoskeletal causes—vertebral artery dissection requires prompt evaluation 5, 8