This protocol applies to patients with vertebral artery dissection in whom bleeding risk is not elevated (moderate bleeding risk), and high-risk radiological features are absent — specifically, no intraluminal thrombus and a nonocclusive dissection pattern.
Risk stratification is guided by radiological assessment: factors associated with intracranial hemorrhage risk and factors associated with ischemic stroke risk — such as the presence of intraluminal thrombus and high-grade stenosis or occlusion — are evaluated to determine which management pathway is appropriate.
In this population, the management strategy for secondary stroke prevention involves an endovascular approach. The full protocol specifies the criteria that determine when this applies, along with the alternative when it is not feasible.
DOI: 10.1161/STR.0000000000000457
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.
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