This protocol applies to patients with vertebral artery dissection whose bleeding risk is not elevated or is at moderate bleeding risk, and who have high-risk radiological features — specifically the presence of intraluminal thrombus or an occlusive/high-grade stenotic dissection.
Patients are stratified according to radiological factors that raise the risk of ischemic stroke — including the presence of intraluminal thrombus and high-grade stenosis or occlusion — as well as factors associated with intracranial hemorrhage risk (such as large infarct, hemorrhagic transformation, and intracranial extension of the dissection). This protocol targets those in whom the ischemic risk features predominate and bleeding risk is not elevated.
When high-risk radiological features are present and bleeding risk permits, the antithrombotic strategy involves a dual antiplatelet approach as the preferred initial course — with the full regimen, duration, sequencing, and transition criteria available in the structured protocol below.
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).
Although the evidence for use in cervical artery dissection is weak, a short course of dual antiplatelet therapy with a loading dose (followed by single antiplatelet agent) might be preferred over monotherapy when deemed safe, particularly in patients who would have qualified for the dual antiplatelet trials for early prevention after minor stroke/TIA.
Patients without radiographic high-risk features or those with an elevated risk of extracranial hemorrhage or ICH (eg, large infarct size, hemorrhagic transformation, intradural extension of extracranial dissection) may be better suited for antiplatelet therapy, with either antiplatelet monotherapy or a short course of dual antiplatelet therapy for 21 to 90 days (in line with minor stroke/TIA and CADISS) if considered safe, followed by single antiplatelet therapy.
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