Treatment for Vertebral Artery Tear

Medical Management

• The American College of Cardiology recommends anticoagulation therapy for at least 3 months in patients with vertebral artery tears and angiographic evidence of thrombus in the extracranial portion of the vertebral artery 1, 2, 3
• Antiplatelet therapy, with aspirin (75-325 mg daily) as first-line therapy, is recommended for patients without evidence of thrombus, according to the American Heart Association 4
• For patients with acute ischemic syndromes involving the vertebral artery territory with angiographic evidence of thrombus, anticoagulation is recommended for at least 3 months, whether or not thrombolytic therapy is used initially, as suggested by the American College of Cardiology 2, 3, 4
• The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo, with a strength of evidence rated as moderate, according to the American Heart Association 3, 4

Diagnostic Approach

• The American Heart Association recommends MRA or CTA over ultrasound for evaluation of vertebral arteries, with a sensitivity of 94% vs 70%, due to their higher diagnostic accuracy 3, 4
• Catheter-based contrast angiography is typically required before revascularization for patients with symptomatic posterior cerebral ischemia, as neither MRA nor CTA reliably delineates the origins of the vertebral arteries, according to the American College of Cardiology 1, 2, 3

Surgical and Endovascular Management

• For proximal vertebral artery reconstruction, early complication rates range from 2.5% to 25% with perioperative mortality rates of 0% to 4%, as reported by the American College of Cardiology 2, 5
• Surgical approaches, including trans-subclavian vertebral endarterectomy, transposition of the vertebral artery to the ipsilateral common carotid artery, and reimplantation of the vertebral artery with vein graft extension to the subclavian artery, are recommended for patients with severe bleeding or where embolization has failed, according to the American Heart Association 3, 5
• Endovascular treatment (angioplasty and stenting) carries risks, including death (0.3%), periprocedural neurological complications (5.5%), and posterior stroke (0.7%), with a strength of evidence rated as low, according to the American College of Cardiology 3, 4
• Restenosis occurs in approximately 26% of proximal vertebral artery interventions, as reported by the American Heart Association 3, 4

Special Considerations

• For patients with subclavian steal syndrome, extra-anatomic carotid-subclavian bypass is recommended in the absence of clinical factors predisposing to surgical morbidity, according to the American Heart Association 3
• When both vertebral arteries are patent and one has a significant stenotic lesion, the contralateral vertebral artery usually supplies sufficient blood flow to the basilar artery, provided there is anatomic continuity, as suggested by the American College of Cardiology 5, 6
• Monitoring for recurrent symptoms and considering serial noninvasive imaging to assess progression is recommended, with a strength of evidence rated as moderate, according to the American Heart Association 4