What is the management of a suspected vertebral artery stroke?

Management of Suspected Vertebral Artery Stroke

The management of suspected vertebral artery stroke should follow a systematic approach beginning with prompt imaging to confirm diagnosis, followed by anticoagulation for at least 3 months in cases with extracranial vertebral artery thrombus. 1

Initial Assessment and Diagnosis

Imaging Studies

• First-line imaging: Non-contrast CT scan to distinguish ischemic from hemorrhagic stroke 2
• Vascular imaging:
  • CTA or contrast-enhanced MRA (sensitivity 94%, specificity 95%) are superior to ultrasound (sensitivity 70%) for vertebral artery stenosis 1
  • Neither MRA nor CTA reliably delineates vertebral artery origins; catheter-based angiography may be required before revascularization 1

Clinical Presentation

Vertebral artery stroke may present with:

• Dizziness, vertigo
• Diplopia
• Perioral numbness
• Blurred vision
• Tinnitus
• Ataxia
• Bilateral sensory deficits
• Syncope 1

Caution: These symptoms can also be caused by other conditions including cardiac arrhythmias, orthostatic hypotension, and vestibular disorders 1

Acute Management

Medical Therapy

1. For acute ischemic syndromes with angiographic evidence of thrombus in extracranial vertebral artery:

   • Anticoagulation with heparin followed by warfarin for at least 3 months, whether or not thrombolytic therapy is used initially 1

2. For eligible patients within time window:

   • IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset 2
   • Ensure BP <185/110 mmHg before administration 2

3. Antiplatelet therapy:

   • Aspirin (160-325 mg) within 48 hours of ischemic stroke onset (after hemorrhage is ruled out) 2
   • For patients with contraindications to aspirin, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 1

Secondary Prevention

Medical Management

• Antiplatelet therapy options:
  • Aspirin alone
  • Combination of aspirin plus dipyridamole (shown to reduce vertebrobasilar territory stroke or TIA to 5.7% compared with 10.8% with placebo) 1
  • Ticlopidine (superior to aspirin for secondary prevention in patients with symptomatic posterior circulation disease) 1
  • Warfarin (equally efficacious to aspirin after initial non-cardioembolic ischemic stroke, per WASID trial) 1

Risk Factor Management

• Control hypertension
• Statin therapy for lipid management
• Lifestyle modifications (smoking cessation, diet, exercise) 2

Revascularization Considerations

Indications for Revascularization

• Persistent or recurrent symptoms despite medical therapy
• Significant stenosis causing hemodynamic compromise

Surgical Options

• Rarely performed for vertebral artery occlusive disease 1
• For proximal vertebral artery reconstruction:
  • Early complication rates: 2.5-25%
  • Perioperative mortality: 0-4% 1
• For distal vertebral artery reconstruction:
  • Mortality rates: 2-8% 1
• Surgical approaches include:
  • Trans-subclavian vertebral endarterectomy
  • Transposition of vertebral artery to ipsilateral common carotid artery
  • Reimplantation with vein graft extension 1

Endovascular Options

• Technically feasible but insufficient evidence from randomized trials to demonstrate superiority over medical management 1
• Outcomes from case series:
  • Proximal vertebral artery stenosis (300 interventions):
    • Death risk: 0.3%
    • Periprocedural neurological complications: 5.5%
    • Posterior stroke risk: 0.7% at mean follow-up of 14.2 months
    • Restenosis: 26% after mean of 12 months 1
  • Distal vertebrobasilar disease (170 angioplasty procedures):
    • Neurological complications: 24% (up to 80% in urgent revascularization)
    • Restenosis: 10% after mean follow-up of 12.6 months
    • Annual stroke risk: approximately 3% 1

Special Considerations

Vertebral Artery Dissection

• Anticoagulation with heparin followed by warfarin is generally recommended 3
• Endovascular treatment may be considered for:
  • Patients with contraindications to anticoagulation
  • Ineffective anticoagulation
  • Progressive symptoms despite medical therapy 3, 4
• Monitor for complications including pseudoaneurysm formation, recurrent stroke, and late thrombosis 5

Subclavian Steal Syndrome

• Consider in patients with posterior cerebral circulatory insufficiency aggravated by upper limb exercise 1
• May present with lightheadedness, syncope, vertigo, ataxia, diplopia, motor deficits or upper limb claudication 1
• Duplex ultrasonography may identify reversal of flow in a vertebral artery 1

Important: Stroke is an emergency, and any delay in starting therapy after an acute stroke will result in progressive, irreversible loss of brain tissue. Remember that "time is brain tissue." 6, 7