Vertebral Artery Dissection with High-Risk Radiological Features and Moderate Bleeding Risk

This protocol addresses the specific situation of vertebral artery dissection when bleeding risk is not elevated but is assessed as moderate, and imaging reveals high-risk radiological features — particularly intraluminal thrombus, occlusive dissection, or high-grade stenotic dissection. These features carry meaningful risk of ischemic stroke and require a tailored approach that accounts for both ischemic and hemorrhagic considerations.

Clinical Scenario

Patients are stratified by radiological risk profile. This scenario applies when: bleeding risk is not elevated / moderate and imaging demonstrates intraluminal thrombus, occlusive dissection, or high-grade stenotic dissection. These findings represent important radiological risk factors for ischemic stroke and inform the choice of intervention.

Treatment Approach (Partial Overview)

In this setting, an endovascular procedure may be considered for secondary stroke prevention. The full protocol specifies when this is appropriate, what criteria must be met, and which alternative approach applies when the primary option is not feasible — details available below.

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References

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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