What is the clinical significance of vertebrobasilar and carotid dolichoectasia (Dolichoectasia, a condition characterized by the dilation and elongation of arteries)?

From the Guidelines

Vertebrobasilar carotid dolichoectasia is clinically significant and requires management with antiplatelet or anticoagulant therapy to prevent recurrent ischemic events in patients with a history of ischemic stroke or TIA without other attributable causes. This condition, characterized by elongation, widening, and tortuosity of the vertebrobasilar arteries, can lead to ischemic stroke due to altered blood flow dynamics, thrombus formation, and subsequent embolism 1. Patients may experience brainstem compression resulting in cranial nerve palsies, particularly affecting the trigeminal, facial, and vestibulocochlear nerves, causing symptoms like facial pain, weakness, hearing loss, and vertigo.

Management and Prevention

Management typically involves:

• Antiplatelet therapy with aspirin (81-325 mg daily) or clopidogrel (75 mg daily) to prevent thromboembolic events
• Blood pressure control is essential, targeting levels below 140/90 mmHg using medications like ACE inhibitors, ARBs, or calcium channel blockers
• Regular monitoring with MRI/MRA every 1-2 years is recommended to assess disease progression Surgical interventions are generally reserved for severe cases with recurrent symptoms despite medical management, as procedures carry significant risks 1.

Patient Education and Follow-up

Patients should be educated about:

• Recognizing stroke symptoms (FAST: facial drooping, arm weakness, speech difficulties, time to call emergency services)
• Maintaining regular follow-up with neurology specialists The condition's pathophysiology involves arterial wall degeneration with elastin fragmentation and smooth muscle atrophy, often associated with aging, hypertension, and atherosclerosis. Despite some knowledge gaps in the management of patients with vertebrobasilar dolichoectasia, including the optimal type and dosing regimens of antiplatelet therapy versus anticoagulation, current guidelines support the use of antiplatelet or anticoagulant therapy for prevention of recurrent ischemic events 1.

From the Research

Clinical Significance of Vertebrobasilar Carotid Dolichoectasia

The clinical significance of vertebrobasilar carotid dolichoectasia is a complex and multifaceted issue. Key points to consider include:

• The condition is characterized by dilatation, elongation, and tortuosity of the brain arteries, most frequently involving the vertebral and basilar arteries, but can also involve the carotid artery system 2, 3.
• Patients with vertebrobasilar dolichoectasia are at high risk of ischemic stroke, brainstem compression, and death, with estimated 5-year complication risks of 17.6% for ischemic stroke, 10.3% for brainstem compression, and 36.2% for case fatality 4.
• Hemorrhagic complications, such as subarachnoid hemorrhage and other intracranial hemorrhage, are less common, with estimated 5-year risks of 2.6% and 4.7%, respectively 4.
• The 5-year prognosis is more favorable in patients who are asymptomatic at the time of diagnosis 4.
• The pathophysiology of vertebrobasilar dolichoectasia is unique, and its prevalence and risks of ischemic stroke and intracranial hemorrhage both increase as the degree of arterial dolichoectasia extends, making management a challenge 5.

Management and Treatment

Management of vertebrobasilar carotid dolichoectasia is crucial to prevent complications. Key points to consider include:

• Controlling arterial hypertension is essential in managing vertebrobasilar dolichoectasia 5.
• Regular follow-up with image studies is necessary to detect early extension of the degree of dolichoectasia 5.
• The use of antiplatelet agents and anticoagulants may be considered, but the risk of bleeding must be carefully weighed against the potential benefits 5.
• Angiotensin receptor blockers, such as losartan, may have antiatherosclerotic effects and could be considered as part of the management strategy 6.