What is the recommended management for an elderly male patient with neck pain and right upper extremity pain and numbness, who has an MRI showing a tortuous and dilated left vertebral artery with probable dissection?

Management of Vertebral Artery Dissection with Posterior Circulation Symptoms

Immediate Diagnostic Confirmation

CT angiography (CTA) of the head and neck with IV contrast should be performed immediately to confirm the vertebral artery dissection, as it has 100% sensitivity compared to MRA (77%) and is the preferred initial diagnostic modality. 1

• The imaging must include the entire vertebral artery from its origin at the aortic arch to the basilar artery, as symptomatic dissection can involve any portion of the vessel 1
• CTA allows evaluation of luminal caliber, detection of filling defects, and assessment of the dissection flap 1
• If CTA is contraindicated or inconclusive, MRA of the head and neck with contrast is the alternative, though less sensitive 1
• Catheter-based digital subtraction angiography should be reserved for cases where non-invasive imaging is inconclusive or when endovascular intervention is being considered 1

Antiplatelet and Anticoagulation Therapy

Initiate antiplatelet therapy immediately with aspirin (81-325 mg daily) as the first-line medical management for vertebral artery dissection with ischemic symptoms. 2

• When angiographic evidence of thrombus is present at the extracranial portion of the vertebral artery, anticoagulation is generally recommended for at least 3 months 2
• The combination of aspirin (75-325 mg daily) plus extended-release dipyridamole is reasonable, as vertebrobasilar territory stroke or TIA occurred in only 5.7% of patients treated with this combination versus 10.8% with placebo 2
• For patients in whom aspirin is contraindicated, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 2
• Aspirin and warfarin have been shown to be equally efficacious for secondary prevention after initial noncardioembolic ischemic stroke in the vertebral artery territory 2

Serial Imaging and Monitoring

Serial noninvasive imaging of the extracranial vertebral arteries at regular intervals is reasonable to assess disease progression and exclude new lesions. 2

• Follow-up imaging should be performed to monitor for complications such as aneurysm formation, progression of stenosis, or development of new lesions 2
• Close cardiac monitoring is essential in the acute phase, as vertebral artery dissection can cause lateral medullary syndrome with severe bradycardia requiring temporary pacemaker placement 3
• Vital signs should be closely monitored to prevent sudden death from life-threatening arrhythmias that can occur with brainstem involvement 3

Consideration for Endovascular Intervention

Endovascular treatment with coiling or stenting should be considered for patients who experience recurrent ischemic events despite optimal medical therapy. 4

• Percutaneous angioplasty and stenting is reasonable for patients at high risk of surgical complications 2
• Endovascular coiling has been successfully used to prevent catastrophic cerebral ischemia in vertebral artery dissection refractory to medical therapy 4
• Catheter-based angiography may be useful to define vertebral artery pathoanatomy when noninvasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization 2

Critical Clinical Pitfalls

Maintain a high index of suspicion for vertebral artery dissection in younger patients with posterior circulation stroke symptoms, as it accounts for 10-15% of ischemic strokes in patients under 45 years. 1

• The contralateral (right-sided) symptoms in this patient with left vertebral artery dissection suggest either embolic phenomena or hemodynamic compromise affecting the posterior circulation 2
• Bilateral vertebral artery involvement can occur and carries risk of basilar artery territory infarction, which can be fatal 5
• Recent infections (including COVID-19) have been identified as potential triggers for vertebral artery dissection 4
• Minor trauma or even trivial mechanisms can cause dissection, and "spontaneous" dissections may be associated with underlying conditions like fibromuscular dysplasia 6