Vertebral Artery Dissection

Aka: Vertebral Artery Dissection, Vertebral Dissection, Vertebrobasilar Dissection

1. See Also
   1. Cervical Artery Dissection
   2. Cerebrovascular Accident of Vertebral Artery
   3. Vertebral Artery Injury in Blunt Neck Trauma
   4. Carotid Artery Dissection
2. Epidemiology
   1. Incidence: 1 to 1.5 per 100,000
   2. Cerebroarterial Dissections (Carotid Artery and Vertebral Artery) are uncommon (<2%) causes of Ischemic CVA
   3. Age
      1. Younger patients account for up to 25% of Vertebral Dissection related Ischemic CVA
      2. Peak Incidence age 50-60 years
   4. Gender
      1. Women are affected at a younger age than men
3. Pathophysiology
   1. Vertebral Artery Dissection most commonly occurs with compression at one of two foramina
      1. Cervical foramen at C1-2
      2. Transverse foramen at C5-6
   2. Vertebral Artery media tear (middle muscular, arterial layer) allowing blood intrusion into arterial wall
      1. Resulting intramural thrombus occludes vessel with risk of CVA
4. Causes
   1. See Cervical Artery Dissection
5. Types
   1. Ischemic Vertebral Artery Dissection
      1. Resulting cerebral ischemia or infarction
      2. Many dissections heal spontaneously and occluded vessels may be compensated by opposite Vertebral Artery
   2. Rupture of Intradural Vertebral Artery dissecting aneurysm (hemorrhagic)
      1. Subarachnoid Hemorrhage
      2. Unstable with high risk of recurrent bleeding (70% of cases, most within first week, and mortality 47%)
6. Findings
   1. Extracranial Vertebral Artery Dissection (primarily at C1-2)
      1. Occipitocervical region severe pain
         1. Unilateral Neck Pain and Headache
      2. Vertebrobasilar Ischemia or Infarction Symptom
         1. Dizziness
         2. Vertigo
         3. Diplopia
         4. Ataxia
         5. Dysarthria
      3. Vertebrobasilar Infarction
         1. Cerebellar infarction
         2. Spinal Cord Infarction
            1. See Spinal Cord Syndrome
         3. Wallenberg Syndrome (lateral Medullary ischemia)
            1. Dysmetria, Ataxia and ipsilateral Hemiplegia
   2. Intracranial Vertebral Artery Dissection
      1. Subarachnoid Hemorrhage in 50% of cases
      2. High rebleeding rate, poor prognosis, high mortality
      3. Responsible for up to 10% of non-Traumatic Subarachnoid Hemorrhage
      4. May be minor in some cases
7. Imaging
   1. MR Angiogram
      1. Has largely replaced CT Angiogram as gold standard, with similar efficacy
   2. CT Angiogram
      1. As with MRA, CT angiogram has high Test Sensitivity
8. Prognosis
   1. Extracranial Vertebral Artery Dissection
      1. No deficit 50%
      2. Mild deficit 21%
      3. Moderate to severe deficit 25%
      4. Mortality 4%
   2. Intracranial Vertebral Artery Dissection
      1. Associated with severe neurologic deficits
9. Management
   1. Anticoagulation (unless contraindicated, e.g. Hemorrhage)
      1. Intravenous Heparin, then
      2. Oral Anticoagulant
   2. Surgical interventions
      1. Endovascular procedures
      2. Vascular or Neurosurgery
10. References
    1. Hussein and Leiman (2022) Crit Dec Emerg Med 36(8): 4-8
    2. Park (2008) J Korean Neurosurg Soc 44:109-15 [PubMed]