What is the treatment for an occluded vertebral artery?

Treatment of Occluded Vertebral Artery

Medical management is the first-line treatment for vertebral artery occlusion, with antiplatelet therapy, statin therapy, and risk factor modification as the cornerstone of treatment, while revascularization procedures should be considered only for patients with persistent symptoms despite optimal medical therapy. 1, 2

Initial Medical Management

For All Patients with Vertebral Artery Occlusion:

• Antiplatelet therapy:

  • Aspirin 75-325 mg daily 1, 2
  • Alternative options: ticlopidine or combination of aspirin plus extended-release dipyridamole 2

• Statin therapy: Target total cholesterol <200 mg/dL 1

• Risk factor modification:

  • Blood pressure control: Target <140/90 mmHg 1
  • Smoking cessation
  • Diabetes management
  • Weight management
  • Physical activity

Special Considerations:

• For acute ischemic syndromes with angiographic evidence of thrombus in extracranial vertebral artery:
  • Anticoagulation for at least 3 months is generally recommended, regardless of initial thrombolytic therapy 2

Diagnostic Evaluation

• Evaluate contralateral vertebral artery patency and dominance 2
• Assess for subclavian steal syndrome if symptoms are aggravated by upper-limb exercise 2
• For patients with symptoms suggesting posterior cerebral or cerebellar ischemia:
  • MRA or CTA is recommended rather than ultrasound imaging 1
  • Catheter-based contrast angiography can be useful when noninvasive imaging fails to define location or severity of stenosis 1
• For dynamic occlusion (with head rotation), dynamic angiography is essential for diagnosis 3

Revascularization Considerations

When to Consider Revascularization:

Revascularization should be considered when patients experience:

• Persistent symptoms despite optimal medical therapy 1, 2
• Recurrent vertebrobasilar TIAs or strokes despite medical management 1, 2

Revascularization Options:

1. Endovascular Management:

   • May be considered for proximal or distal vertebral artery stenosis 2
   • Risks:
     • Death: approximately 0.3% for proximal interventions
     • Periprocedural neurological complications: 5.5% for proximal, 24% for distal interventions
     • Restenosis: 26% for proximal, 10% for distal interventions after 12 months 2

2. Surgical Management:

   • Rarely performed but may be considered for proximal or distal vertebral artery reconstruction 2
   • Risks:
     • Early complication rates: 2.5-25% for proximal reconstruction
     • Perioperative mortality: 0-4% for proximal, 2-8% for distal reconstruction 2

3. For Subclavian Steal Syndrome:

   • Extra-anatomic carotid-subclavian bypass is reasonable for symptomatic posterior cerebral or cerebellar ischemia 1, 2
   • Percutaneous endovascular angioplasty and stenting is reasonable for patients at high risk of surgical complications 1, 2

Follow-up Management

• Serial noninvasive imaging of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization 1

Pitfalls and Caveats

• Mortality risk in vertebral artery occlusion is not negligible (reported as high as 25% in older studies) 4
• Benign segmental and proximal occlusion with adequate compensation must be distinguished from segmental distal occlusion and extensive occlusion, which carry higher risk 4
• For rotational vertebral artery occlusion, misdiagnosis of the site of occlusion or missing a second occlusive site is common without dynamic angiography 3
• In patients without a posterior inferior cerebellar artery (PICA) or with a low PICA origin, the anterior spinal artery may play a crucial role in preventing thrombus propagation and supplying blood to perforating arteries 5