Vertebral Artery Dissection Diagnosis and Management

Clinical Presentation

Vertebral artery dissection typically presents with headache, neck pain, vertigo, nausea, visual disturbances, or syncope in patients, according to the American Heart Association 1, 2
Some patients develop sudden catastrophic neurological events, while others have a more gradual onset of symptoms, as reported by the American College of Cardiology 2, 3
After initial warning symptoms, cerebral or retinal ischemia develops in 50-95% of cases, as stated by the American Heart Association 1, 4

Sudden or excessive neck movement (hyperflexion/hyperextension) is a risk factor for vertebral artery dissection, as noted by the American Heart Association 1, 4
Minor trauma including chiropractic manipulation is also a risk factor, according to the American Heart Association 5, 4
Fibromuscular dysplasia (associated with approximately 15% of cases) is a risk factor for vertebral artery dissection, as reported by the American Heart Association 1, 4

CT Angiography (CTA) of the head and neck with IV contrast is the preferred initial diagnostic modality with the highest reported sensitivity (100%), as recommended by the American College of Radiology 6, 7
MR Angiography (MRA) has a sensitivity of approximately 77% compared to conventional angiography, as stated by the American College of Radiology 6, 7

Antithrombotic treatment for at least 3-6 months is recommended for patients with vertebral artery dissection associated with ischemic stroke or TIA (Class IIa recommendation), as recommended by the American Heart Association 5, 7
Options include anticoagulation with heparin, low-molecular-weight heparin, or warfarin (target INR 2.0-3.0), as noted by the American College of Cardiology 5, 7
Antiplatelet therapy with aspirin, clopidogrel, or the combination of extended-release dipyridamole plus aspirin is also an option, as reported by the American College of Cardiology 5, 7

With appropriate antithrombotic treatment, the prognosis is usually favorable, as stated by the American Heart Association 1, 7
The annual rate of recurrent stroke, TIA, or death was reported as 8.3% in patients treated with anticoagulants versus 12.4% in those treated with aspirin in one observational study, as noted by the American College of Cardiology 7

Brain imaging, such as MRI or CT, should be performed concurrently with CT angiography to assess for ischemic complications, as 50-95% of patients develop cerebral or retinal ischemia after initial warning symptoms, according to the American Heart Association/American Stroke Association 8

Elevated CRP with vertebral dissection does not automatically indicate large vessel vasculitis, as dissection itself can cause inflammatory markers to rise, as stated by the European League Against Rheumatism 9
If CRP elevation is unexplained by the dissection and accompanied by constitutional symptoms, urgent referral to a specialist team for vasculitis evaluation is warranted, as recommended by the European League Against Rheumatism 9

Antithrombotic therapy should be initiated for 3-6 months immediately after diagnosis confirmation, with options including anticoagulation or antiplatelet approaches, and the choice of treatment may be influenced by the presence of intracranial extension or subarachnoid hemorrhage risk, as noted by the American Heart Association/American Stroke Association 8

The headache pattern in vertebral dissection has characteristic features, including acute onset, persistent, severe, throbbing pain in the occipitonuchal region, which may be accompanied by nausea, vomiting, vertigo, visual disturbances, or syncope, as described by the American Headache Society 8

Surgical or endovascular revascularization is reserved exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy, as stated by the American Heart Association/American Stroke Association 8