How to manage a vertebral artery with a potentially unstable plaque or unstable thrombus in a patient with a left posterior cerebral artery (PCA) stroke?

From the Guidelines

Management of a vertebral artery with potentially unstable plaque or thrombus in a patient with left PCA stroke requires immediate antiplatelet therapy with aspirin 325mg loading dose followed by 81mg daily, combined with clopidogrel 300-600mg loading dose followed by 75mg daily for 21-90 days (dual antiplatelet therapy or DAPT). This approach is based on the guidelines for the management of patients with extracranial carotid and vertebral artery disease, which recommend antiplatelet therapy with aspirin or clopidogrel for patients with vertebral atherosclerosis 1.

High-intensity statin therapy with atorvastatin 40-80mg or rosuvastatin 20-40mg daily should be initiated regardless of baseline cholesterol levels to reduce the risk of recurrent stroke and cardiovascular events. Blood pressure should be maintained below 140/90 mmHg using appropriate antihypertensives. Imaging with CT angiography or MR angiography is essential to evaluate the extent of stenosis and plaque characteristics.

For severe stenosis (>70%) or recurrent symptoms despite medical therapy, consider endovascular intervention with stenting or surgical options, as recommended by the guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. Close monitoring with repeat vascular imaging at 1-3 months is recommended to assess plaque stability and treatment response. These interventions aim to stabilize the plaque, prevent further thrombus formation, and reduce the risk of recurrent stroke by addressing inflammation, platelet aggregation, and hemodynamic stress on the vulnerable arterial segment.

Key considerations in the management of vertebral artery disease include:

• Antiplatelet therapy with aspirin or clopidogrel
• High-intensity statin therapy
• Blood pressure control
• Imaging with CT angiography or MR angiography
• Endovascular intervention or surgical options for severe stenosis or recurrent symptoms
• Close monitoring with repeat vascular imaging to assess treatment response.

The guidelines for the management of patients with extracranial carotid and vertebral artery disease provide a framework for the management of vertebral artery disease, and recommend a multidisciplinary approach to reduce the risk of recurrent stroke and cardiovascular events 1.

From the Research

Management of Vertebral Artery with Unstable Plaque or Thrombus

• The management of a vertebral artery with a potentially unstable plaque or unstable thrombus in a patient with a left posterior cerebral artery (PCA) stroke is crucial to prevent further ischemic events.
• According to the study by 2, artery-to-artery embolism from the vertebral artery to the PCA can cause stroke in the posterior circulation, highlighting the importance of managing the vertebral artery to prevent further embolic events.

Treatment Options

• The use of anticoagulants such as rivaroxaban has been studied in patients with embolic stroke of undetermined source and carotid atherosclerosis, as reported by 3.
• However, the study by 3 found no difference in efficacy between rivaroxaban and aspirin for prevention of recurrent stroke in patients with carotid atherosclerosis, but aspirin was safer.
• Another study by 4 compared the combination of anticoagulant or P2Y12 inhibitor with low-dose aspirin versus low-dose aspirin alone in patients at risk or with documented coronary and/or peripheral artery disease, and found that rivaroxaban 2.5 mg twice daily + low-dose aspirin reduced the risk of major adverse cardiovascular events, cardiovascular death, and stroke.

Mechanical Thrombectomy

• Mechanical thrombectomy has been used to treat acute isolated posterior cerebral artery stroke, as reported by 5.
• The study by 5 found that mechanical thrombectomy was a potentially safe and effective treatment modality for acute PCA stroke, with a high rate of successful recanalization and favorable outcomes.

Considerations

• The management of a vertebral artery with a potentially unstable plaque or unstable thrombus requires careful consideration of the patient's individual risk factors and the potential benefits and risks of different treatment options, as discussed by 6 and 4.
• The use of clopidogrel, as reported by 6, may be considered in addition to aspirin, but the duration of clopidogrel use should be carefully monitored to minimize the risk of bleeding.