Vertebral Artery Dissection: Symptoms, Types, Causes and Treatment

Vertebral artery dissection (VAD) is an under-recognized but significant cause of stroke, particularly among young and middle-aged adults. Its diverse presentations can make diagnosis challenging, while its potential consequences—from transient symptoms to life-altering strokes—underscore the importance of early recognition and appropriate management. In this comprehensive article, we explore the symptoms, types, causes, and treatment of vertebral artery dissection, synthesizing the latest evidence and clinical insights.

Symptoms of Vertebral Artery Dissection

Vertebral artery dissection often presents with symptoms that are easy to overlook—such as headache and neck pain—making early diagnosis a clinical challenge. These symptoms can precede more severe neurological events, such as stroke, by days or even weeks. Recognizing the warning signs is crucial for timely intervention and better prognosis.

Symptom	Frequency	Notes / Features	Source(s)
Headache	51–100%	Often occipital/unilateral; prominent warning sign	1 2 4 5
Neck Pain	41–90%	Can precede neurological deficits	1 2 4 5
Dizziness/Vertigo	40–58%	Early and common; may accompany pain	1 2 4 5
Stroke	63%	Most common serious complication	1 2 3
Unilateral Facial Paresthesia	46%	Sensory changes on one side of face	2
Visual Disturbance	15–50%	Blurred/double vision; field defects	2 5
Cerebellar Signs	33%	Ataxia, imbalance	2 3
Subarachnoid Hemorrhage	10%	Only with intracranial dissection	1 3

Table 1: Key Symptoms of Vertebral Artery Dissection

Recognizing the Early Signs

Headache and Neck Pain

• These are the most frequent initial symptoms, often described as sudden, severe, and sometimes unilateral (one-sided) 1 2 4 5.
• Pain may localize to the occipital region or upper neck.
• In up to 53% of patients, these symptoms precede stroke by several days, serving as a warning sign 2 4.

Dizziness and Vertigo

• Dizziness/vertigo occurs in about half of all cases and may be the only presenting symptom 1 2 4 5.
• Vertigo can be persistent or episodic, sometimes leading to misdiagnosis as a benign inner ear problem.

Neurological Deficits

• As the dissection progresses or if stroke occurs, additional symptoms may develop:
  • Unilateral facial numbness or tingling (paresthesia)
  • Double vision or visual field loss
  • Difficulty with balance or coordination (cerebellar signs)
  • Weakness, speech difficulties, or swallowing trouble (brainstem involvement) 2 3.

Subarachnoid Hemorrhage

• Seen in about 10% overall, but much more common in intracranial dissections (up to 57% of such cases) 1 3.
• Presents with sudden, severe headache (thunderclap), neck stiffness, and possible loss of consciousness.

Clinical Course and Prognosis

• In most cases (67–83%), outcomes are good if recognized and managed early 1 2.
• Poor prognosis is linked to bilateral dissections and those with subarachnoid hemorrhage 2.
• Recurrence rates are low, but vigilance is necessary, especially in patients with risk factors or connective tissue disorders 2 3.

Types of Vertebral Artery Dissection

Not all vertebral artery dissections are the same. The anatomical location, mechanism, and clinical consequences help define distinct types, each with implications for prognosis and treatment.

Type	Location	Key Features / Risks	Source(s)
Extracranial	Outside skull base	More common; higher risk of ischemic stroke	1 6 9
Intracranial	Inside skull	Less common; higher risk of subarachnoid hemorrhage	1 3 9
Bilateral	Both arteries	Rare (up to 24%); worse prognosis, higher complication	2 10 12
Traumatic	Related to injury	Often at C1–C2; associated with neck trauma, manipulation	2 6 12 13
Spontaneous	No clear trauma	May be linked to underlying vessel pathology or genetics	6 9 11

Table 2: Types of Vertebral Artery Dissection

Anatomical Classification

Extracranial vs. Intracranial

• Extracranial dissections (most common) occur outside the skull, often at the upper cervical spine level (C1–C2) 1 2 6.
  • More likely to cause ischemic stroke via vessel narrowing or clot formation.
• Intracranial dissections occur within the skull and have a higher risk of causing subarachnoid hemorrhage due to vessel rupture 1 3 9.
  • Less likely to cause ischemic events unless extension compromises blood flow.

Bilateral Dissection

• Involves both vertebral arteries.
• Presents a greater risk for poor outcomes and is often associated with more severe neurological deficits or fatal complications 2 10 12.

Classification by Cause

Traumatic

• Result from direct or indirect injury to the neck—examples include motor vehicle accidents, sports injuries, falls, or chiropractic manipulation 2 6 12 13.
• Dissections from manipulation typically occur at the mobile C1–C2 junction, where the vertebral artery is most susceptible to stretching and torsion 6 13.

Spontaneous

• Occur without obvious trauma and may be associated with underlying vessel weaknesses, connective tissue disorders, or anatomical variations 6 9 11.
• Spontaneous dissections are often bilateral and may be linked to genetic predispositions.

Anatomical Variations

• Recent imaging studies show that certain anatomical variations—such as a dominant vertebral artery or a lateral shift of the vertebrobasilar junction—may predispose individuals to dissection 7.

Causes of Vertebral Artery Dissection

Understanding the causes of vertebral artery dissection is essential for both prevention and early diagnosis. Most cases are multifactorial, involving a combination of mechanical, anatomical, and sometimes genetic factors.

Cause	Description / Example	Relative Frequency / Risk	Source(s)
Trauma	Direct or indirect neck injury	<50% in most series	2 6 12 13
Minor Mechanical Stress	Chiropractic manipulation, sports, yoga	11–15% of cases; often C1–C2	2 6 13
Spontaneous	No clear trauma; may be linked to vessel anomalies	>50% of cases	1 6 9 11
Connective Tissue Disease	Ehlers-Danlos, fibromuscular dysplasia	7.9% of cases	1 6 11
Anatomical Variations	Vessel dominance, tortuosity, junction shift	Increased risk	7

Table 3: Causes and Risk Factors for Vertebral Artery Dissection

Traumatic and Mechanical Causes

• Major Trauma: High-energy injuries (car accidents, falls, severe blows) can directly damage the artery 2 6 12.
• Minor Trauma or Stress: Even seemingly innocuous activities—chiropractic neck manipulation, abrupt head movements, yoga, trampoline exercise—can trigger a dissection when the vessel is stretched or twisted, especially at C1–C2 2 6 13.
• The link between minor trauma and dissection is sometimes debated; often, a temporal relationship is observed, but causality is complex 6.

Spontaneous Dissection

• More than half of vertebral artery dissections occur without identifiable trauma 1 6 9 11.
• These cases may be due to:
  • Underlying vessel wall abnormalities (e.g., fibromuscular dysplasia, Ehlers-Danlos syndrome)
  • Genetic predisposition or subtle anatomical anomalies.

Connective Tissue Disorders

• Conditions like Ehlers-Danlos syndrome or fibromuscular dysplasia weaken arterial walls, increasing susceptibility to dissection even without trauma 1 6 11.
• However, only a minority of patients with VAD have a known connective tissue disorder (around 8%) 1.

Anatomical Variations

• Variations in vessel size, dominance, or the position of the vertebrobasilar junction can increase mechanical stress on the artery and raise the risk of dissection 7.
• Type 3 lateral shift of the vertebrobasilar junction is particularly associated with dissection 7.

Treatment of Vertebral Artery Dissection

Treatment decisions for vertebral artery dissection hinge on the location, severity, and clinical presentation—especially whether the dissection has caused ischemia, subarachnoid hemorrhage, or remains asymptomatic. Management options range from conservative medical therapy to advanced endovascular and, rarely, surgical interventions.

Treatment Option	Indication / Scenario	Efficacy / Outcome	Source(s)
Anticoagulation	Ischemic stroke or infarction; most cases	Standard; low recurrence; good outcome	10 11 15
Antiplatelet Therapy	Alternative to anticoagulation	Sometimes combined; similar effectiveness	10 15
Conservative (Observation)	Asymptomatic or unruptured cases	Most heal spontaneously	15 16
Blood Pressure Control, Bed Rest	Mild, non-hemorrhagic cases	Good recovery; careful monitoring	16
Endovascular Therapy	Aneurysms, failed medical therapy, hemorrhage	Safe, effective, minimal invasiveness	8 14 17 18
Surgery	Refractory or complex cases; PICA involvement	Reserved for select cases	8 15 17

Table 4: Treatment Options for Vertebral Artery Dissection

Medical Management

Anticoagulation and Antiplatelet Therapy

• First-line treatment for most VAD cases, especially those presenting with ischemic symptoms 10 11 15.
• Warfarin, heparin, and aspirin are common agents.
• Dual therapy (anticoagulant plus antiplatelet) has been used successfully in some cases, but evidence for superiority is lacking 10.
• Most dissections heal spontaneously within months, and recurrence is rare 15.

Conservative Management

• Asymptomatic or unruptured intracranial dissections without evidence of infarction or hemorrhage may be managed with observation, blood pressure control, and bed rest 15 16.
• Serial imaging is essential to monitor healing or detect complications 16.

Endovascular and Surgical Treatments

Endovascular Therapy

• Indicated for:
  • Dissecting aneurysms at risk of rupture
  • Failed medical therapy or progressive symptoms
  • Subarachnoid hemorrhage due to intracranial dissection
• Techniques include internal trapping, stent-assisted coiling, and parent artery occlusion 8 14 17 18.
  • Both internal trapping and stent-assisted coiling yield high rates of good outcomes and low recurrence 17 18.
  • For aneurysms involving the posterior inferior cerebellar artery (PICA), bypass or artery-to-PICA stenting may be required 8 17.
• Endovascular treatment is minimally invasive and generally safe, with low morbidity and mortality 8 14 17 18.

Surgical Approaches

• Open microsurgery is rare and reserved for:
  • Patients with persistent symptoms refractory to other treatments
  • Complex dissections not amenable to endovascular therapy
  • Specific vascular anatomy (e.g., pre-PICA, PICA, post-PICA types) 8 15
• Surgical strategies include trapping, bypass grafts, and vessel reconstruction 8.
• Success rates are high when procedures are carefully tailored to anatomy and clinical scenario 8.

Prognosis and Outcomes

• Most patients recover well with appropriate treatment, especially if managed before major neurological events develop 1 2 8 18.
• Bilateral dissections and those presenting with subarachnoid hemorrhage have a worse prognosis 2 18.
• Ongoing research continues to refine guidelines for optimal therapy and follow-up.

Conclusion

Vertebral artery dissection is a complex condition with potentially severe consequences but also a high chance of recovery when recognized and treated early. Awareness of its diverse symptoms, variable presentations, and the full spectrum of management options is vital for clinicians and patients alike.

Key Takeaways:

• Headache and neck pain are the most common and often the earliest symptoms—sometimes preceding more serious neurological signs by days.
• Stroke and vertigo are frequent complications; subarachnoid hemorrhage is rarer and more often linked to intracranial dissections.
• Types of VAD include extracranial, intracranial, bilateral, traumatic, and spontaneous forms—each with different risk profiles and implications.
• Causes range from trauma and minor neck movements to spontaneous events related to vessel wall weakness or anatomical variations.
• Treatment depends on the presentation:
  • Most cases are managed with anticoagulation or antiplatelet therapy.
  • Endovascular techniques are increasingly used for complicated cases or those with aneurysmal change or hemorrhage.
  • Surgery is reserved for select, refractory situations.
• Prognosis is generally favorable, but vigilance is necessary for high-risk presentations.

By maintaining a high index of suspicion—especially in younger patients with unexplained headache, neck pain, or posterior circulation symptoms—clinicians can ensure timely diagnosis and optimal outcomes for vertebral artery dissection.