What is the recommended initial management for an adult with vertebral artery dissection (VAD) and no contraindications?

Management of Vertebral Artery Dissection

For adults with vertebral artery dissection and no contraindications, initiate antithrombotic therapy immediately for 3-6 months using either antiplatelet agents (aspirin 81-325 mg daily or clopidogrel 75 mg daily) or anticoagulation (IV heparin followed by warfarin with target INR 2.0-3.0), as both approaches show equivalent efficacy in preventing recurrent stroke and death. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• CT angiography (CTA) or MR angiography (MRA) are the preferred diagnostic modalities (Class I recommendation) and should be obtained immediately 1
• Avoid relying on carotid duplex ultrasonography alone, as it may miss dissections beginning above the angle of the mandible 1
• Catheter-based angiography may be necessary to delineate collateral filling via the circle of Willis if non-invasive imaging fails to define the location or severity 2

Medical Management Algorithm

Step 1: Choose Antithrombotic Strategy

Both antiplatelet therapy and anticoagulation are equally effective based on the CADISS trial (OR 0.56,95% CI 0.10-3.21), so selection depends on bleeding risk assessment 1:

Option A - Antiplatelet Therapy:

• 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
• Preferred if patient has higher bleeding risk or contraindications to anticoagulation

Option B - Anticoagulation:

• IV heparin immediately, then transition to warfarin (target INR 2.0-3.0) 1
• Results in 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
• Consider this approach if thrombus is visualized at the dissection site on angiography 3

Step 2: Duration and Transition

• Continue initial antithrombotic therapy for 3-6 months (Class IIa recommendation) 1
• After the initial 3-6 month period, transition to long-term antiplatelet therapy 1
• Most dissections heal spontaneously (72-100% anatomic healing with medical management alone) 1

Step 3: Aggressive Risk Factor Modification

Treat according to standards for extracranial carotid atherosclerosis 2:

• High-intensity statin therapy 3
• Blood pressure control with target systolic BP <140 mmHg 3
• At least moderate physical activity 3

Critical Contraindication: Intracranial Extension

Anticoagulation is absolutely contraindicated if subarachnoid hemorrhage occurs from intracranial extension of the dissection, as intracranial vertebrobasilar dissections carry higher rupture risk 1. The risk of hemorrhagic transformation with appropriate patient selection remains low (<5%) 1.

When to Consider Endovascular Intervention

Reserve angioplasty and stenting ONLY for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy 1, 3. Do not use as initial treatment even in severe cases 3.

Be aware of significant intervention risks:

• 5.5% periprocedural neurological complications 1
• 26% restenosis rate at 12 months 1
• 0.3% death risk and 0.7% posterior stroke risk at 14.2 months 1

Follow-Up Imaging Strategy

• Serial non-invasive imaging (CTA or MRA) is reasonable to assess disease progression and exclude new lesions 2
• 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
• If revascularization was performed, surveillance imaging at 1 month, 6 months, then annually is reasonable 3

Special Considerations for Thrombolysis

Vertebral artery dissection is NOT an absolute contraindication to IV thrombolysis if the patient presents within the therapeutic window for acute ischemic stroke 4, 5. Case reports demonstrate safety and efficacy of recombinant tissue-plasminogen activator in VAD-related stroke with complete vascular healing at 3 months 4.

Prognosis

With appropriate antithrombotic treatment, the prognosis is usually favorable 1. Complete vascular healing can occur within 3 months in many cases 4, and patients can return to normal activities with proper management 4.