From the Guidelines
The management of chronic vertebral artery occlusion should primarily focus on secondary stroke prevention and symptom control, with antiplatelet therapy being the cornerstone of treatment, as recommended by the most recent guidelines 1. The first-line option for antiplatelet therapy is aspirin (75-325 mg daily), with alternatives including clopidogrel (75 mg daily) or the combination of aspirin plus extended-release dipyridamole (25/200 mg twice daily) 1. Some key points to consider in the management of chronic vertebral artery occlusion include:
- Risk factor modification, including blood pressure control (target <140/90 mmHg), lipid management with high-intensity statins, diabetes management (target HbA1c <7%), smoking cessation, and lifestyle modifications such as regular exercise and a Mediterranean diet.
- For patients with recurrent symptoms despite medical therapy, endovascular intervention with angioplasty and stenting may be considered, particularly for proximal vertebral artery stenosis, as supported by recent guidelines 1.
- Surgical options like vertebral endarterectomy or bypass procedures are rarely performed due to technical challenges and limited evidence, but can be considered in experienced centers with low stroke/death rates 1. Regular follow-up is important to monitor for neurological symptoms, medication adherence, and risk factor control, addressing the underlying pathophysiology by preventing further atherosclerotic progression and reducing the risk of thromboembolic events in the posterior circulation. Key considerations for treatment are based on the most recent and highest quality study available 1, which provides guidance on the management of peripheral arterial and aortic diseases, including vertebral artery stenosis.
From the Research
Management Options
The management of chronic vertebral artery (VA) occlusion can involve various approaches, including:
- Anticoagulation therapy: This has been shown to be effective in treating patients with posterior circulation ischemic strokes after VA occlusion, without the need for surgical or endovascular treatment 2.
- Endovascular treatment: This can be a safe and effective option for treating symptoms caused by posterior circulation ischemia, with high technical and clinical success rates, low complication rates, and durable long-term results 3.
- Stent retriever angioplasty: This approach has been shown to be a viable option for managing acute atherosclerotic occlusion, using the deploy and re-sheath method 4.
- Extracranial to intracranial bypass: This surgical procedure can be used to treat symptomatic non-atherosclerotic bilateral extracranial VA occlusion 5.
- Therapeutic occlusion: This can be achieved using a Penumbra occlusion device system and Ruby coils, and has been shown to be effective in achieving VA occlusion 6.
Treatment Considerations
When considering treatment options for chronic VA occlusion, it is essential to take into account the individual patient's circumstances, including the presence of atherosclerotic disease, the severity of symptoms, and the risk of complications.
- Patients who fail medical therapy may be considered for endovascular stenting for symptomatic VA stenosis 3.
- The use of stent retriever angioplasty may be considered for acute atherosclerotic occlusion, particularly in cases where mechanical thrombectomy is challenging 4.
- Therapeutic occlusion may be considered in cases where VA occlusion is necessary, such as in the treatment of malignant tumors 6.