This protocol addresses vertebral artery dissection in patients whose bleeding risk is not elevated (low bleeding risk) and who have radiological findings that place them at heightened risk for ischemic stroke. Risk stratification distinguishes between radiological factors that predict ischemic stroke and those that signal intracranial hemorrhage risk; this protocol applies when the balance favours intervention.
The defining radiological findings that characterise this sub-population are:
These features are recognised predictors of ischemic stroke following dissection. Their presence — in the setting of low bleeding risk — informs the management approach described in this protocol.
In this setting, an endovascular procedure may be considered as a measure for secondary stroke prevention in select patients. The full protocol specifies under what conditions this approach is appropriate and what alternative intervention is reserved for cases where the primary approach is not feasible.
DOI: 10.1161/STR.0000000000000457
The presence of radiographic high-risk features that are known predictors of ischemic stroke after dissection (such as severe stenosis or occlusion, intraluminal thrombus) in patients with low risk of bleeding may warrant anticoagulation therapy.
Patients are stratified according to radiological risk factors for intracranial hemorrhage (eg, large infarct, hemorrhagic transformation, and intracranial extension of the dissection) and important radiological risk factors for ischemic stroke (eg, presence of intraluminal thrombus and high-grade stenosis or occlusion).
Angioplasty and stenting may be fairly safe and beneficial in a limited population of patients with flow-limiting stenosis who fail medical treatment.
Patients with cervical artery dissection with significant stenosis causing distal hemodynamic compromise AND recurrent ischemic stroke despite optimal medical treatment AND who can withstand surgery may be considered for stenting as a measure for secondary stroke prevention.
When angioplasty and stenting are not feasible, vessel sacrifice may be considered in patients with recurrent ischemic stroke but adequate compensatory circulation.