What is the management of vertebral artery stenosis in the emergency department?

Emergency Department Management of Vertebral Artery Stenosis

Medical therapy is the first-line treatment for vertebral artery stenosis in the emergency department, with antiplatelet therapy being the cornerstone of management for most patients. 1

Initial Assessment and Diagnosis

• Evaluate for symptoms suggesting posterior circulation ischemia including vertigo, diplopia, ataxia, bilateral sensory deficits, and syncope 1
• MRA or CTA is recommended rather than ultrasound for evaluation of vertebral arteries in patients with suspected posterior cerebral or cerebellar ischemia 1
• Catheter-based contrast angiography can be useful when noninvasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization 1
• Digital subtraction angiography (DSA) is considered the gold standard for diagnosis but has associated morbidity risks 2

Medical Management

• Antiplatelet therapy is the cornerstone of management for vertebral artery stenosis 1:

  • Aspirin (75-325 mg daily) is recommended as first-line therapy 1
  • For patients with aspirin contraindications, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 1
  • The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo 1

• For patients with acute ischemic syndromes involving the vertebral artery territory with angiographic evidence of thrombus in the extracranial portion:

  • Anticoagulation is generally recommended for at least 3 months, whether or not thrombolytic therapy is used initially 1
  • The WASID trial found aspirin and warfarin to be equally efficacious after initial noncardioembolic ischemic stroke 1

• Risk factor modification and lifestyle changes should follow the same guidelines as for carotid artery disease 1

Revascularization Considerations

• Revascularization (surgical or endovascular) should be considered only when medical therapy fails to control symptoms 1, 2

• Endovascular treatment (angioplasty and stenting):

  • There is insufficient evidence from randomized trials that endovascular management is superior to best medical management 1
  • Consider for symptomatic patients with refractory symptoms despite optimal medical therapy 3
  • Risks include death (0.3%), periprocedural neurological complications (5.5%), and posterior stroke (0.7%) 1
  • Restenosis occurs in approximately 26% of proximal vertebral artery interventions 1

• Surgical management:

  • Operations are rarely performed for vertebral artery occlusive disease 1
  • No randomized trials have addressed operative procedures for posterior cerebral circulation disease 1
  • Surgical options include trans-subclavian vertebral endarterectomy, transposition of the vertebral artery to the ipsilateral common carotid artery, and reimplantation of the vertebral artery 1
  • Early complication rates range from 2.5% to 25% and perioperative mortality rates from 0% to 4% for proximal vertebral artery reconstruction 1

Special Considerations

• For subclavian steal syndrome (symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis):

  • Extra-anatomic carotid-subclavian bypass is reasonable in the absence of clinical factors predisposing to surgical morbidity or mortality 1
  • Percutaneous endovascular angioplasty and stenting is reasonable for patients at high risk of surgical complications 1

• Monitor for recurrent symptoms and consider serial noninvasive imaging to assess progression of atherosclerotic disease 1

Emergency Department Algorithm

1. Stabilize patient and assess for acute stroke symptoms
2. Obtain appropriate neuroimaging (preferably MRA or CTA) 1
3. Initiate antiplatelet therapy unless contraindicated 1
4. For patients with acute thrombus in the extracranial vertebral artery, consider anticoagulation 1
5. Consult neurology or vascular specialists for patients with severe stenosis or ongoing symptoms despite initial management 1, 2
6. Consider transfer to a center with endovascular capabilities for patients who might benefit from intervention 4, 5