From the Guidelines
For moderate stenosis of the proximal intracranial segment of the left vertebral artery likely due to calcified plaque, the primary treatment is medical management with antiplatelet therapy, as the risks of interventional procedures often outweigh benefits in this scenario. I recommend starting with aspirin 81-325 mg daily, with many clinicians preferring 81 mg for long-term use to minimize bleeding risk, as supported by guidelines from the American Heart Association/American Stroke Association 1. Adding clopidogrel 75 mg daily may be considered for dual antiplatelet therapy initially, typically for 3-6 months in higher-risk cases, before transitioning to aspirin monotherapy. A high-intensity statin such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily should be prescribed regardless of baseline cholesterol levels to stabilize the plaque and reduce stroke risk, in line with recommendations for secondary stroke prevention 1. Blood pressure should be controlled to a target below 140/90 mmHg using appropriate antihypertensives, as recommended by guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. Lifestyle modifications are essential, including smoking cessation, regular physical activity, diabetes management if applicable, and a Mediterranean or DASH diet.
Key Components of Medical Management:
- Antiplatelet therapy with aspirin and potentially clopidogrel for dual antiplatelet therapy in selected cases
- High-intensity statin therapy for plaque stabilization and stroke risk reduction
- Blood pressure control below 140/90 mmHg
- Lifestyle modifications including diet, exercise, and smoking cessation
Considerations for Interventional Procedures:
Endovascular or surgical interventions are typically reserved for severe stenosis (>70%), particularly in symptomatic patients who fail medical therapy, due to the associated risks and lack of clear benefit for moderate stenosis, as indicated by guidelines and studies 1. Regular follow-up imaging every 6-12 months is recommended to monitor for progression of stenosis. The most recent and highest quality guidelines support a conservative approach for moderate stenosis, emphasizing the importance of medical management and lifestyle modifications to reduce morbidity, mortality, and improve quality of life 1.
From the Research
Treatment Options for Moderate Stenosis of Proximal Intracranial Segment of the Left Vertebral Artery
The treatment for moderate stenosis of the proximal intracranial segment of the left vertebral artery likely due to calcified plaque includes:
- Aggressive medical therapy, which has been shown to be effective in preventing recurrent stroke in high-risk patients with atherosclerotic stenosis of a major intracranial artery 2
- Endovascular therapy, such as stent-assisted angioplasty, which has been used to treat intracranial vertebrobasilar atherosclerosis 3
- Angioplasty and/or stenting, which has been shown to be effective in treating symptomatic intracranial vascular stenosis 4
- Endovascular stenting, which has been demonstrated to be safe and effective for symptomatic vertebral artery stenosis 5
Considerations for Treatment
When considering treatment options, the following factors should be taken into account:
- The risk of recurrent stroke, which is high in patients with atherosclerotic intracranial arterial stenosis 2
- The potential benefits and risks of each treatment option, including the risk of periprocedural complications 3, 4
- The durability of symptom resolution, which has been shown to be high with endovascular stenting 5
- The need for further research to identify high-risk subgroups and develop more effective treatments 2
Non-Invasive Vascular Imaging Methods
Non-invasive vascular imaging methods, such as:
- Fractional flow on magnetic resonance angiography (MRA)
- Quantitative MRA
- High-resolution MRI of the atherosclerotic plaque can be used to identify high-risk patients and monitor the effectiveness of treatment 2