What is the treatment for vertebrobasilar insufficiency?

Treatment of Vertebrobasilar Insufficiency

Medical management following guidelines similar to those for carotid artery disease is the first-line treatment for vertebrobasilar insufficiency, with antiplatelet therapy as the cornerstone of treatment. 1, 2

Diagnosis and Evaluation

• Evaluation should begin with thorough clinical assessment followed by non-invasive imaging, with CTA and contrast-enhanced MRA having higher sensitivity (94%) and specificity (95%) than ultrasonography (70%) 3
• Common symptoms include dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, and imbalance 2
• Catheter-based angiography is typically required before revascularization for symptomatic patients as MRA and CTA do not reliably delineate the origins of the vertebral arteries 3, 1

Medical Management Algorithm

• First-line treatment: Antiplatelet therapy for all symptomatic patients 1, 2
• For acute ischemic syndromes with angiographic evidence of thrombus in the extracranial vertebral artery: Anticoagulation for at least 3 months, regardless of whether thrombolytic therapy is used initially 3, 1
• For long-term secondary prevention:
  • Combination of aspirin plus dipyridamole has shown benefit (5.7% vs 10.8% recurrent stroke rate compared to placebo) 3, 1
  • Ticlopidine has demonstrated superiority to aspirin for secondary prevention in patients with symptomatic posterior circulation disease 3, 4
  • The WASID trial found aspirin and warfarin to be equally efficacious after initial noncardioembolic ischemic stroke 3

Revascularization Options

Surgical Approaches

• Operations are rarely performed to treat vertebral artery occlusive disease due to lack of randomized trial evidence 3
• For proximal vertebral artery reconstruction: Early complication rates of 2.5-25% and perioperative mortality rates of 0-4% 3, 1
• For distal vertebral artery reconstruction: Mortality rates range from 2-8% 3
• Intracranial bypass surgery: Associated with mortality rates of 3-12% and neurological/systemic complication rates of 22-55% 3, 1
• Surgical options include:
  • Trans-subclavian vertebral endarterectomy 3
  • Transposition of vertebral artery to ipsilateral common carotid artery 3
  • Reimplantation of vertebral artery with vein graft extension 3
  • Anastomosis of external carotid artery to vertebral artery 3

Endovascular Management

• Limited evidence from randomized trials comparing endovascular management to best medical therapy 3, 1
• For proximal vertebral artery stenosis (300 interventions reviewed):
  • Death risk: 0.3% 3, 1
  • Periprocedural neurological complications: 5.5% 3, 1
  • Posterior stroke at mean follow-up of 14.2 months: 0.7% 3, 1
  • Restenosis: 26% after mean of 12 months (not consistently correlated with recurrent symptoms) 3, 1
• For distal vertebrobasilar disease (170 angioplasty procedures):
  • Neurological complications: 24% (approaching 80% in urgent revascularization) 3
  • Restenosis: 10% after mean follow-up of 12.6 months 3
  • Annual stroke risk after angioplasty: approximately 3% 3, 2

Special Considerations

• Endovascular treatment should be reserved for selected patients with recurrent ischemic symptoms and progressive disability despite maximal medical therapy 5, 6
• Surgical revascularization should be considered in patients with VBI who remain symptomatic despite a protracted course of maximal medical therapy, especially those with large and medium-sized vessel occlusions and poor collateral circulation 7
• Combining medical therapies with endovascular interventions may improve outcomes and reduce restenosis rates 6

Common Pitfalls and Caveats

• Vertebrobasilar disease is often underdiagnosed - it may be the causative basis for approximately 20% of posterior circulation strokes 3, 2
• Routine screening for posterior circulation disease as an etiology for stroke is rarely performed, leading to underdiagnosis 8
• The risk of stroke and restenosis appears to be related to more distal and anatomically complex lesions 3
• There is a lack of large randomized trials comparing treatment options, making definitive recommendations challenging 6, 9