What are the current guidelines for managing a traumatic vertebral artery dissection?

Management of Traumatic Vertebral Artery Dissection

For traumatic vertebral artery dissection, initiate antithrombotic therapy immediately for 3-6 months using either anticoagulation (IV heparin followed by warfarin with target INR 2.0-3.0) or antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily), as both approaches show equivalent efficacy in preventing recurrent ischemic events. 1

Diagnostic Approach

Imaging modality selection:

• CT angiography (CTA) of the head and neck with IV contrast is the preferred initial diagnostic test, with 100% sensitivity compared to MRA (77%) and Doppler ultrasound (71%). 2
• Imaging must include the entire vertebral artery from its origin at the aortic arch to the basilar artery, as dissection can occur at any point along this course. 2
• Perform concurrent brain imaging (MRI or CT) to assess for ischemic complications, since 50-95% of patients develop cerebral or retinal ischemia after initial warning symptoms. 3
• Carotid duplex ultrasonography has limited utility for dissections beginning above the angle of the mandible and is more operator-dependent. 4, 2

Clinical presentation to recognize:

• Headache and neck pain (often localized to the site of intimal disruption), vertigo, nausea, visual disturbances, or syncope. 4, 3
• Horner syndrome may be present. 4
• Symptoms may be delayed from hours to weeks after the traumatic event. 5, 6
• In patients with severe cervical spine trauma (luxation, subluxation, or fracture), symptoms of vertebral artery dissection may be masked by spinal cord injury symptoms. 6

Medical Management Algorithm

Initial antithrombotic therapy (choose one approach):

Option 1 - Anticoagulation:

• Start IV heparin immediately, then transition to warfarin (target INR 2.0-3.0). 1
• This yields a 1% stroke/death rate at 3 months and 1.6% at 1 year. 1
• Annual recurrent stroke/TIA/death rate is 8.3% with anticoagulation. 1, 3

Option 2 - Antiplatelet therapy:

• Aspirin 81-325 mg daily or clopidogrel 75 mg daily. 1, 3
• This yields a 2% stroke/death rate at 3 months and 3.2% at 1 year. 1
• Annual recurrent stroke/TIA/death rate is 12.4% with aspirin alone. 1, 3
• Consider aspirin plus extended-release dipyridamole 200 mg twice daily, which reduced vertebrobasilar territory stroke/TIA from 10.8% to 5.7% compared to placebo. 1

The choice between anticoagulation and antiplatelet therapy should be based on bleeding risk and patient-specific factors, as the CADISS trial showed no statistically significant difference between approaches (OR 0.56,95% CI 0.10-3.21). 1

Duration:

• Continue antithrombotic therapy for 3-6 months. 1, 3
• After the initial 3-6 month period, transition to antiplatelet therapy. 1

Critical Contraindication

Anticoagulation is absolutely contraindicated if subarachnoid hemorrhage occurs from intracranial extension of the dissection, as intracranial vertebrobasilar dissections carry higher rupture risk. 1, 3 This is a common pitfall that can adversely influence outcomes. 4

Endovascular or Surgical Intervention

Reserve invasive treatment exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy. 1, 3

Endovascular options:

• Angioplasty and stenting may be considered when ischemic neurological symptoms have not responded to antithrombotic therapy. 4, 1
• Periprocedural risks include 5.5% neurological complications, 0.3% death risk, 0.7% posterior stroke risk, and 26% restenosis rate at 12 months. 1

Surgical options:

• Direct vertebral artery repair or resection with vein graft replacement. 1

Prognosis and Follow-up

With appropriate antithrombotic treatment, the prognosis is usually favorable, with anatomic healing occurring in 72-100% of patients with medical management alone. 4, 1, 3

Key prognostic points:

• 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
• Maintain high suspicion in younger patients, as vertebral artery dissection accounts for 10-15% of ischemic strokes in patients under 45 years. 2

Special Considerations for Trauma Context

In patients with severe cervical spine trauma (fracture, luxation, or subluxation):

• Perform early Doppler ultrasound and duplex sonography as noninvasive screening, as symptoms of vertebral artery dissection may be disguised by signs of spinal injury. 6
• The dissection is typically located at the site of vertebral injury or cranial to it. 6
• Head and neck pain localized to the site of intimal disruption may be the only early sign before catastrophic vertebrobasilar infarction develops. 6