What is the management guideline for vertebral artery origin stenosis after a stroke?

Management of Vertebral Artery Origin Stenosis After Stroke

For patients with vertebral artery origin stenosis after stroke, optimal medical therapy is recommended as first-line treatment, which should include antiplatelet therapy, statin therapy, and risk factor modification. 1

Initial Assessment and Diagnosis

• Non-invasive imaging with CTA or MRA should be part of the initial evaluation for patients with neurological symptoms referable to the posterior circulation 1
• MRA or CTA is preferred over ultrasound for evaluation of vertebral arteries in patients with posterior cerebral or cerebellar ischemic symptoms 1
• Catheter-based contrast angiography can be useful when non-invasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization 1

Medical Management (First-Line Treatment)

Antiplatelet Therapy

• Aspirin (75-325 mg daily) is recommended for all patients with vertebral artery atherosclerosis 1
• Alternative antiplatelet options include:
  • Aspirin (81-325 mg daily)
  • Combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily)
  • Clopidogrel (75 mg daily) 1

Risk Factor Modification

• Blood pressure control: Target <140/90 mmHg 1
• Lipid management: Target total cholesterol <200 mg/dL 1
• Smoking cessation
• Diabetes management
• Weight management and physical activity

Revascularization Considerations

When to Consider Endovascular or Surgical Treatment

• Endovascular and surgical treatment may be considered only when patients continue to have symptoms despite optimal medical treatment (Class IIb; Level of Evidence C) 1
• The VIST trial suggested that vertebral artery stenting might be associated with reduced recurrent stroke risk, particularly for extracranial vertebral artery stenosis where complication rates were very low, though the study was underpowered 2

Monitoring After Treatment

• For patients who undergo vertebral artery revascularization, serial non-invasive imaging is reasonable at intervals similar to those for carotid revascularization 1
• Be aware of potential complications after stenting:
  • In-stent restenosis (reported rates vary from 5.3% with drug-eluting stents 3 to 45% with other stent types 4)
  • Stent fracture (reported in approximately 10.5% of cases) 3

Clinical Pearls and Pitfalls

• Patients with symptomatic vertebral artery stenosis may have a higher recurrent stroke risk in the first 7 days after symptom onset compared to patients with recently symptomatic carotid stenosis 1
• The annual event rate for posterior circulation ischemic stroke is significantly higher in patients with symptomatic VAO stenosis than in those with asymptomatic stenosis (1.88% vs. 0%) 5
• Drug-eluting stents may have lower in-stent restenosis rates compared to bare metal stents 3
• Medical therapy has generally been the mainstay of treatment due to the high rate of morbidity associated with surgical correction 1

Special Considerations

• For patients with both carotid and vertebral artery disease requiring cardiac surgery, carotid revascularization before or concurrent with myocardial revascularization surgery is reasonable in patients with >80% carotid stenosis who have experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months 1
• Asymptomatic vertebral artery stenosis generally has a more favorable prognosis than symptomatic stenosis 5

Remember that while endovascular intervention shows promise, particularly for extracranial vertebral artery stenosis, current guidelines still recommend optimal medical therapy as the first-line approach, with revascularization reserved for those who remain symptomatic despite medical management.