Case study: vertebral dissection 

Young person, trauma, some C2 fractures. Concern for R vertebral artery dissection. 

Thoughts: 

- Clots respond to flow. In a case of complete occlusion leading, the clot will propagate to the nearest point of flow-- in this case, the original occlusion/dissection was at C2-3, and the occlusion is complete. We would expect it to go all the way down to the origin. It hasn't -- there are 2 reasons. One is that there might not have been enough time. Two is that there are vessels causing flow somewhere along V1 or V2 keeping the vert patent. Big muscular branches or there's sometimes a big radiculomedullary branch (analogous to artery of adamkiewicz) that comes off around C5-6 -- this is very important; occlusion of this vessel may compromise high cervical spine vascular supply. One might think, in a case where the vert is still partially filling, if we fully occlude the vert there will be a lower stroke risk -- that might be the case, but if the vert is patent because there is flow to a large radiculomedullary branch, occluding it might lead to a devastating outcome.

- Complete occlusions typically do not have to be treated with anticoagulation as they are low embolic stroke risks. Partial or recannalized verts typically do have to be anticoagulated.