Purpose <p>Traumatic vertebral artery injury (TVAI) poses a risk for ischemic stroke, often requiring prompt antithrombotic therapy. However, when concomitant neurosurgical intervention is necessary, concerns regarding perioperative bleeding frequently lead to delays in antithrombotic initiation. This study evaluates the impact of delayed antithrombotic therapy on stroke risk in TVAI patients undergoing neurosurgical interventions.</p> Methods <p>A retrospective review was conducted of a TVAI registry over 7 years (2016–2023) at a level 1 trauma center for patients who were treated with antithrombotics for stroke prevention. Baseline demographics, vertebral artery injury characteristics, concomitant injury characteristics, acute management and outcomes were compared between surgical and non-surgical cohorts. Statistical analyses included Student’s t-test, Chi-square tests, relative risk (RR), and attributable risk (AR).</p> Results <p>Among the 121 patients, 44 (36.4%) underwent neurosurgical procedures. The surgical cohort experienced an average 2-day delay in antithrombotic initiation (<i>p</i> &lt; 0.001). The incidence of stroke in the neurosurgical intervention group was 20.5%, which was significantly higher than 5.19% in the control group (<i>p</i> = 0.016), with an associated RR of 3.94 and excess AR of 15.3%. No significant differences in baseline antithrombotic use, injury severity, or mortality were observed between cohorts.</p> Conclusion <p>Delayed antithrombotic initiation in TVAI patients undergoing neurosurgical intervention is associated with a nearly fourfold increased risk of stroke. Future multi-center studies should explore neurosurgical strategies allowing safer early antithrombotic initiation in this patient population.</p> Clinical trial number <p>not applicable</p>