Vertebral artery dissection
A tear in the vertebral artery wall, spontaneous or from neck trauma or manipulation, that causes posterior circulation ischemia through thrombus formation or direct luminal narrowing. Presents with posterior neck or occipital headache plus brainstem or cerebellar signs, most classically a lateral medullary (Wallenberg) syndrome; diagnosed with MRI/MRA or CT angiography of the neck and treated with antithrombotic therapy.
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What this article covers
- Overview
A tear in the vertebral artery wall: vertebral artery dissection occurs when blood enters a tear between the layers of the arterial wall, creating an intramural hematoma that can narrow the true…
- Epidemiology
Uncommon but disproportionately important in young stroke: cervicocephalic (carotid and vertebral) dissection accounts for a small overall share of all strokes but a substantial share of strokes in…
- Risk factors
Cervical spine manipulation: aggressive chiropractic neck manipulation is a recognized precipitant of vertebral artery dissection with resulting stroke.
- Pathophysiology
Intimal or medial tear initiates the dissection: a tear, spontaneous or traumatic, in the vessel wall allows blood into the media, creating an intramural hematoma that expands within the wall.
- Clinical features
Posterior neck or occipital headache is the presenting symptom in most patients, often a new, unusually severe, or unfamiliar headache, frequently preceding focal neurologic symptoms by hours to days.
- Differential diagnosis
Carotid artery dissection: the anterior-circulation counterpart, presenting with unilateral head, face, or neck pain, partial Horner syndrome, and anterior-circulation deficits such as contralateral…
- Diagnosis
A crescentic intramural hematoma, intimal flap, double lumen, tapered luminal narrowing, or pseudoaneurysm on vessel imaging establishes the diagnosis; clinical suspicion from the…
- Management
First step: assess for large-vessel occlusion physiology and eligibility for reperfusion therapy, since a dissection can present with an acute, evolving posterior circulation stroke requiring the…
- Complications
Recurrent or extending stroke in the days to weeks after the initial dissection, while the hematoma and thrombogenic surface remain active.
- Prognosis
Most patients have a favorable long-term outcome: most vertebral dissections heal with arterial recanalization over weeks to months, and patients without a large infarct at presentation recover well.
- Prevention
Avoid unnecessary aggressive cervical spine manipulation, particularly high-velocity rotational maneuvers, in patients with a known connective tissue disorder or prior dissection.
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Related articles
- Carotid artery dissection
Carotid artery dissection is a tear in the wall of the internal carotid artery creating an intramural hematoma, typically presenting with unilateral head, face, or neck pain, partial Horner syndrome, and ischemic stroke or transient ischemic attack in a young or middle-aged patient. Diagnosis is by MRA or CTA of the neck, and most patients are treated with antiplatelet or anticoagulant therapy.
- Cerebellar stroke
Cerebellar stroke, ischemic or hemorrhagic infarction of the cerebellum, presents with vertigo, truncal ataxia, dysarthria, and limb incoordination and is diagnosed with brain MRI when CT is falsely reassuring. Its defining danger is delayed swelling that compresses the brainstem and fourth ventricle, which is treated with emergent decompressive suboccipital craniectomy.
- Basilar artery occlusion
Basilar artery occlusion is a posterior circulation large-vessel stroke that threatens the brainstem, cerebellum, and thalami, presenting with rapidly progressive quadriparesis, cranial nerve palsies, and impaired consciousness, up to locked-in syndrome or coma. Diagnosis requires urgent CT angiography, and management is emergent reperfusion with IV alteplase followed by mechanical thrombectomy in eligible patients.
- Subarachnoid hemorrhage
Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space, most often from a ruptured saccular (berry) aneurysm, presenting as the worst headache of a patient's life. Diagnosis is noncontrast head CT, then lumbar puncture if CT is negative, then catheter angiography to define the aneurysm; management is early aneurysm securement, blood pressure control, and nimodipine to reduce delayed cerebral ischemia from vasospasm.
- Horner syndrome
Horner syndrome is an oculosympathetic palsy causing the ipsilateral triad of miosis, partial ptosis, and anhidrosis from a lesion anywhere along the three-neuron sympathetic pathway to the eye and face. Diagnosis is clinical, confirmed with apraclonidine or cocaine eye drops; management targets the underlying cause, which ranges from benign to an emergent carotid dissection or Pancoast tumor.
- Ischemic stroke
Ischemic stroke is sudden focal neurologic deficit from arterial occlusion confirmed by infarction on neuroimaging. Diagnosis relies on urgent noncontrast head CT to exclude hemorrhage; treatment is IV alteplase within 4.5 hours and mechanical thrombectomy for large-vessel occlusion within an extended window, followed by antiplatelet therapy and risk-factor control.