Management of Vertebrobasilar Dolichoectasia
For patients with vertebrobasilar dolichoectasia (VBD), antiaggregant therapy is the first-line treatment for those with previous ischemic events, while anticoagulation should be avoided in patients with hemorrhagic symptoms or high bleeding risk factors. 1
Understanding Vertebrobasilar Dolichoectasia
Vertebrobasilar dolichoectasia is a rare condition characterized by significant expansion, elongation, and tortuosity of the vertebrobasilar arteries 2. It presents with various clinical manifestations including:
- Ischemic stroke (most common)
- Progressive compression of cranial nerves and brainstem
- Cerebral hemorrhage
- Hydrocephalus
Risk Assessment and Diagnostic Approach
Proper evaluation requires:
- Contrast-enhanced MRA or CTA (94% sensitivity, 95% specificity) 3
- Catheter-based angiography (typically required before any revascularization) 3
- Assessment of risk factors for hemorrhage:
- Uncontrolled hypertension
- History of previous hemorrhage
- Concomitant use of antiaggregants
- Presence of microhemorrhages on MRI
- Large associated fusiform aneurysms 1
Treatment Algorithm
1. For VBD with Previous Ischemic Events:
- First-line treatment: Antiaggregant therapy
- Aspirin 50-325 mg/day OR
- Clopidogrel 75 mg/day 1
- Close monitoring for signs of bleeding
- Regular follow-up neuroimaging to evaluate progression of dilation
2. For VBD with High Thrombotic Risk but No Previous Events:
- Simple antiaggregation therapy
- Strict control of vascular risk factors, especially hypertension 1
3. For Acute Ischemic Syndromes in Vertebral Artery Territory with Thrombus:
- Anticoagulation for at least 3 months, whether or not thrombolytic therapy is used initially 3
- Consider intravenous thrombolysis in select cases of intraluminal thrombus, though risk/benefit must be carefully assessed 4
4. Situations to Avoid Anticoagulation:
- Rapidly documented growth of dolichoectasia
- Uncontrolled arterial hypertension
- Presence of microhemorrhages on MRI
- Large associated fusiform aneurysms 1
Interventional Options
Interventional options should be considered with caution as evidence is limited:
Surgical Options:
- Trans-subclavian vertebral endarterectomy
- Transposition of vertebral artery to ipsilateral common carotid artery
- Reimplantation of vertebral artery with vein graft extension 3
Endovascular Management:
- Limited evidence that endovascular management is superior to best medical management
- Risks of proximal vertebral artery intervention: death (0.3%), periprocedural neurological complications (5.5%), posterior stroke (0.7%)
- Restenosis occurs in approximately 26% of cases after 12 months 3
Prognosis and Monitoring
VBD carries significant risks over time:
- 5-year risk of ischemic stroke: 17.6%
- 5-year risk of brainstem compression: 10.3%
- 5-year risk of TIA: 10.1%
- 5-year risk of hemorrhagic stroke: 4.7%
- 5-year case fatality rate: 36.2% 5
Patients with basilar artery involvement have 4.4 times higher risk of posterior circulation dysfunction 6.
Key Considerations and Pitfalls
- Avoid anticoagulation in patients with hemorrhagic risk factors
- Recognize that VBD can present with both ischemic and hemorrhagic complications
- Understand that basilar artery involvement significantly increases neurological morbidity
- Regular monitoring is essential as the condition can progress over time
- Surgical and endovascular interventions carry significant risks and should be considered only in selected cases where medical management fails