Spontaneous Intracranial Vertebral Artery Dissection: A Rare Cause of Ischemic Stroke

The dissection of the V4 vertebral artery (VA) is the most prevalent form of intracranial dissection, which can manifest either as ischemia or as a subarachnoid hemorrhage (SAH). Patient outcomes are significantly affected by their initial presentation; ischemic symptoms often indicate that the dissection remains primarily subintimal or within the medial layer, though it can occasionally extend to the basilar artery. In contrast, patients with ruptured VA dissection (VAD) experience a considerably higher mortality rate, as the dissection can reach the adventitial layer, heightening the risk of recurrent hemorrhage. It can show fluctuating imaging findings, making an accurate diagnosis and timely treatment essential. Currently, there are no established diagnostic criteria for VAD, and its diagnosis largely depends on imaging. The presence of intramural hematoma, identified via three-dimensional, black-blood, T1-weighted imaging, has been recognized as the most reliable indicator for diagnosing VAD and is crucial for establishing a definitive diagnosis. DSA remains a fundamental diagnostic technique not only in hemorrhagic patients but also in ischemic patients. The medical treatment of ischemic patients has not yet been well defined, and evidence-based data are lacking. This review aims to summarize the main clinical, pathophysiological, and neuroradiological features of intracranial VAD presenting with ischemic stroke, providing to clinicians the available information in order to individualize the treatment.