Treatment of Vertebral Artery Dissection With Elevated Risk of Extracranial or Intracranial Hemorrhage
Vertebral artery dissection management must be adjusted when the patient's clinical picture raises the risk of hemorrhagic complications. In this setting, the standard antithrombotic approach may not be appropriate, and a different strategy is required.
Clinical Situation
This protocol applies to patients with vertebral artery dissection who have an elevated risk of extracranial hemorrhage — such as a recent hemorrhage — or an elevated risk of intracranial hemorrhage, including large infarct size, hemorrhagic transformation, or intradural extension of the extracranial dissection.
Treatment Approach (Overview)
For patients in whom medical management is insufficient, the protocol addresses a procedural vascular intervention — specifically angioplasty and stenting — as a measure for secondary stroke prevention, along with a defined alternative when that intervention is not feasible. Precise eligibility criteria, sequencing, and the full decision pathway are contained in the complete protocol.
References
DOI: 10.1161/STR.0000000000000457
- 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.
- 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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