What is the emergent care of vertebral artery dissection (VAD)?

Updated: Feb 21, 2019
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Patients who demonstrate significant neurologic deficits merit transport to stroke centers or other health care institutions able to offer appropriate care of either spontaneous or traumatic vertebral artery dissection (VAD).

Immediate management for dissections leading to acute ischemia includes the initiation of thrombolytic agents provided there are no contraindications to their administration. This therapy is best reserved for patients presenting within 4.5 hours of symptom onset. Beyond this phase, treatment with either anticoagulation or antiplatelet agents are the treatments of choice.

The accepted management of proven or suspected spontaneous VAD consists of antithrombotic therapy (with either antiplatelet or anticoagulant agents) in those patients who are not also affected by the complication of subarachnoid hemorrhage. [13, 39] This approach is intended to prevent thrombogenic or embolic occlusion of the vertebrobasilar network and subsequent infarction of posterior CNS structures, brain stem, and cerebellum.

Data guiding this management strategy comes from the 2015 Cervical Artery Dissection in Stroke Study (CADISS) trial discussed in the Medical Care section. [40] The pathophysiologic mechanism underlying VAD includes hemorrhage into the arterial wall and subarachnoid hemorrhage as a devastating complication of the condition.


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