Vertebral Artery Dissection

What is vertebral artery dissection?

A dissection is a tear in one or more tissue layers that make up your vertebral artery. Vertebral artery dissection is a rare cause of stroke in older adults. It’s more common in people younger than 45.

What is the vertebral artery?

You have two vertebral arteries that run along the back of your neck near your spine bones (vertebrae). They deliver oxygen-rich blood to your brain and spine.

The vertebral artery has three layers:

• Intima, inner layer closest to blood flow.
• Media, middle layer that keeps blood flowing in the right direction.
• Adventitia, outermost layer that gives the blood vessel structure.

How can vertebral artery dissection affect my health?

With a dissection, blood gets trapped between the intima and media. Blood that’s not moving can form a clot, creating a bulge that disrupts blood flow. It can also lead to swelling (dilation) of the artery.

In the most severe cases, vertebral artery dissection causes stroke:

• Ischemic stroke occurs when a clot becomes large enough to block blood flow to your brain. Clots can also break off, travel through your bloodstream and get trapped in an artery downstream.
• Hemorrhagic stroke occurs when a dissection affects all three layers of artery tissue. This causes blood to spill out of the artery instead of reaching your brain. If the dissection reaches inside of your brain, this can cause bleeding into the space around your brain (subarachnoid hemorrhage) or into the brain itself.

Who gets vertebral artery dissection?

In some people, vertebral artery dissection occurs for no known reason. You may face a higher risk of dissection if you have certain health conditions, including:

• Smoking.
• Cystic medial necrosis.
• Ehlers-Danlos syndrome.
• Fibromuscular dysplasia.
• High blood pressure in the arteries supplying your lungs and heart (arterial hypertension).
• Marfan syndrome.
• Osteogenesis imperfecta.
• Polycystic kidney disease.
• Vasculitis.

Are there additional risk factors for vertebral artery dissection?

Injury can also cause dissection. This can happen by keeping your neck in a hyper-flexed position (looking upward) for extended periods. It may also occur with sudden neck movements and trauma.

Activities and other situations that can lead to vertebral artery dissection include:

• Car accidents.
• Chiropractic adjustment or deep tissue neck massage.
• Blowing your nose too hard.
• Practicing yoga where hyperextension of your neck occurs.
• Painting a ceiling with your neck in an extended position for a long time.
• Receiving cardiopulmonary resuscitation.
• Sneezing.
• Vomiting.
• Wrestling.
• Heavy weight lifting.
• Other causes of neck injury.

Can other types of artery dissection lead to stroke?

Cervical artery dissection includes tears in the arteries of your neck. These include vertebral and carotid arteries. Your two carotid arteries run along either side of your neck in the front. Dissection in either artery can disrupt blood flow and potentially cause a stroke.

What is the stroke risk?

Your chances of experiencing a stroke are low. Vertebral and carotid artery dissections account for only 2% of ischemic strokes. Most of the time, ischemic stroke is due to atherosclerosis (thickening of the artery from other risk factors, such as smoking, high blood pressure, high cholesterol, diabetes).

However, vertebral artery dissection is a common cause of stroke in young and middle-aged adults. Up to 25% of stroke cases in this age group are due to vertebral artery dissection.

What are the symptoms of vertebral artery dissection?

In earlier stages, you might not notice symptoms. If the artery ruptures or a blood clot disrupts blood flow to your brain, you may experience signs of a stroke.

Symptoms include:

• Ataxia (trouble with balance or coordination).
• Dizziness.
• Hearing loss.
• Double vision.
• Neck pain (usually one-sided).
• Severe headaches.
• Slurred speech (dysarthria).
• Vertigo.

How is vertebral artery dissection diagnosed?

Magnetic resonance angiography is the gold standard diagnostic test. It combines magnetic resonance imaging (MRI) with angiography to capture detailed images of your vertebral arteries. This method enables healthcare providers to quickly pinpoint the dissection and determine its severity and acuity.

Magnetic resonance angiography is a sophisticated test that’s not widely available. Healthcare providers can often diagnose a vertebral artery dissection with a computed tomography (CT) scan or CT angiography. These are typically among the first tests people receive.

Sometimes, your healthcare provider may recommend conventional angiography. This is a procedure where a provider places catheters (long, thin tubes) in either your wrist or groin. They’ll use contrast dye and X-ray-guided imaging to look at blood flow through the artery itself along with the extent of the dissection or vessel injury in real-time.

How is vertebral artery dissection treated?

Most dissections heal on their own. To reduce the risk of blood clots, you may receive blood-thinning medications as a first-line therapy such as aspirin or aspirin-like medications (Plavix®), heparin infusion or warfarin tablets. If the dissection reaches your brain or there’s a hemorrhagic stroke, then blood thinners may not be safe. Your healthcare provider may recommend alternative treatments.

What if standard therapies are not successful?

You may need a procedure. This option is also for people with hemorrhagic stroke.

Procedures for vertebral artery dissection include:

• Endovascular embolization uses catheters (long, thin tubes) placed in either your wrist or groin to access the dissection and either apply an embolic agent or insert tiny metal coils. The agent or coils seal the abnormal vessel, preventing blood from flowing through it.
• Angioplasty uses catheters (long, thin tubes) placed in either your wrist or groin to access the dissection and repairs the dissected section of the artery with inflation of a special balloon.
• Intracranial (inside the brain) stenting uses catheters (long, thin tubes) placed in either your wrist or groin to access the dissection and place a mesh-like metal device to reinforce the walls of the blood vessel. This may be appropriate for select people.
• Oftentimes, providers perform angioplasty and stenting.
• Surgery may be necessary if you can’t have an endovascular procedure as above. During surgery, healthcare providers seal off the abnormal vessel using tiny metal clips.

What is the prognosis for people with vertebral artery dissection?

Most people make a full recovery. However, you may be at risk for future dissections. This risk decreases over time.

What’s it like living with a vertebral artery dissection?

You’ll need regular monitoring until healthcare providers confirm that healing has taken place. Monitoring typically includes magnetic resonance angiography every three to six months. You may also need to continue taking a blood thinner during this time. Individuals facing a higher risk of future dissection will need follow-up care for many years.

Is there anything I should avoid after having a vertebral artery dissection?

You can still exercise but should avoid the following:

• Push-ups and pull-ups or other similar exercises where you support your body weight with your hands/arms.
• Lifting more than 25 to 30 pounds.
• Overhead lifting.
• Contact sports.
• Roller coaster rides.
• Chiropractor head/neck manipulation.
• Deep tissue massage on your neck.
• Sky diving.
• Other activities with rapid acceleration/deceleration changes.
• “Plank” position (but otherwise safe to participate in yoga or Pilates).
• Any activities that could result in whiplash injury or extended periods of hyperextension of your neck.

A note from Cleveland Clinic

Vertebral artery dissection occurs when a tear forms in one of the blood vessels running up the back of your neck. On rare occasions, this can lead to stroke. But timely treatment, typically blood thinners or a procedure, can save your life. Medical therapy and ongoing monitoring can help people with vertebral artery dissection avoid complications.