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Management of patient with vertebral artery dissection (Master thesis)

Μουτζουρούνης, Απόστολος/ Moutzourounis, Apostolos

Vertebral artery dissection (VAD) is one of the most common causes of ischemic stroke in young adults. It is usually related to a prior major or minor cervical trauma, but sometimes it could occur spontaneously, in people with or without genetic risk factors. Headache or neck pain is the most frequent symptom, and it is often followed by focal neurological deficits due to ischemia. The pathophysiological mechanisms of these symptoms include distal embolization, hemodynamic compromise due to arterial stenosis, local compression syndromes due to pseudoaneurysm formation, and subarachnoid hemorrhage due to arterial rupture. Although conventional angiography is considered the gold standard in the diagnosis of VAD, computed and/or magnetic resonance angiography are used with increasing frequency in the evaluation of this condition, since they can demonstrate both intraluminal and extraluminal abnormalities, and they are not invasive and widely accessible. Treatment options for cervical artery dissection (CAD), and in particular for VAD, include conservative treatment and surgical or radiological interventions. Intravenous thrombolysis in general should not be withheld in patients with dissection-related ischemic stroke, since some studies have confirmed its safety and effictiveness in these patients. There is a discussion regarding the appropriate antithrombotic agent (anticoagulants or antiplatelets) for preventing stroke in these patients, but there is not statistically significant difference in effectiveness between those two treatment options. Thus, the decision must be individualized based on clinical/imaging characteristics and patient-specific risks. The use of novel oral anticoagulants (NOACs) could be a useful alternative in CAD, with currently encouraging results. Finally, endovascular treatment should be reserved for those in whom neurological symptoms do not resolve or reoccur despite maximum medical therapy or for those with contraindications to antithrombotic treatment, and especially in cases of ruptured dissections. When these methods are applied according to the current indications, they are considered safe and effective in terms of recovery and mortality rate.