From the Guidelines
Management of occlusion with no opacification of the V4 segment of the vertebral artery typically involves immediate antiplatelet therapy with aspirin 75 to 325 mg daily, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. The goal of this management approach is to reduce the risk of recurrent stroke and other ischemic events by addressing the underlying atherosclerotic risk factors.
- Key components of management include:
- Antiplatelet therapy with aspirin to prevent further ischemic events
- Medical therapy and lifestyle modification to reduce atherosclerotic risk, as recommended for patients with extracranial carotid atherosclerosis
- Blood pressure management, although specific targets are not provided in the guideline
- The 2011 guideline also recommends antiplatelet drug therapy as part of the initial management for patients who sustain ischemic stroke or TIA associated with extracranial vertebral atherosclerosis, with options including aspirin, the combination of aspirin plus extended-release dipyridamole, and clopidogrel 1.
- Another study published in 2006 provides additional guidance on antithrombotic therapy for noncardioembolic stroke or TIA, recommending antiplatelet agents rather than oral anticoagulation to reduce the risk of recurrent stroke and other cardiovascular events 1.
- The anatomy of the vertebrobasilar arterial circulation, including the V4 segment of the vertebral artery, is also important to consider in management, as described in the 2011 guideline 1.
From the Research
Management of Occlusion with No Opacification of the V4 Segment of the Vertebral Artery
- The management of occlusion with no opacification of the V4 segment of the vertebral artery involves various treatment strategies, including symptomatic treatment, antithrombotic therapy, and surgical intervention 2, 3.
- According to a study published in 1987, the treatment is often symptomatic only, but surgery of the proximal vertebral artery may be considered in some cases to prevent occlusion 2.
- Another study published in 2017 reported a case of traumatic vertebral artery occlusion, where the patient underwent a transposition of the vertebral artery to the common carotid artery to augment flow to the posterior circulation 3.
- Antithrombotic therapy, such as antiplatelet therapy or anticoagulation therapy, may also be considered to prevent early neurological deterioration and improve outcomes in patients with ischemic stroke, including those with vertebral artery occlusion 4, 5, 6.
- A study published in 2015 found that low-molecular-weight heparin or dual antiplatelet therapy was more effective than aspirin alone in preventing early neurological deterioration and improving the 6-month outcome in ischemic stroke patients 5.
- Another study published in 2002 reported the use of low-molecular-weight heparin for vertebral artery dissection, which resulted in complete recanalization of the basilar artery 6.
Treatment Options
- Symptomatic treatment 2
- Antithrombotic therapy, including antiplatelet therapy or anticoagulation therapy 4, 5, 6
- Surgical intervention, such as transposition of the vertebral artery to the common carotid artery 3
- Low-molecular-weight heparin or dual antiplatelet therapy 5
Key Considerations
- The choice of treatment depends on the individual patient's condition and the severity of the occlusion 2, 3.
- Antithrombotic therapy may be considered to prevent early neurological deterioration and improve outcomes in patients with ischemic stroke, including those with vertebral artery occlusion 4, 5, 6.
- Surgical intervention may be considered in cases where the occlusion is causing significant hemodynamic compromise or impending vertebrobasilar insufficiency 3.