Management of Right Vertebral Artery Collapse
The management of right vertebral artery collapse should follow a structured approach beginning with antiplatelet therapy as first-line treatment, with aspirin (75-325 mg daily) recommended for patients without evidence of thrombus. 1, 2
Diagnostic Approach
- MRA or CTA is recommended over ultrasound for evaluation of vertebral arteries due to higher diagnostic accuracy (sensitivity 94% vs 70%) 1, 3
- Catheter-based contrast angiography is typically required before revascularization for patients with symptomatic posterior cerebral ischemia, as neither MRA nor CTA reliably delineates the origins of the vertebral arteries 3, 1
- Common symptoms to evaluate include dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope 4
Medical Management
- For patients without evidence of thrombus, antiplatelet therapy with aspirin (75-325 mg daily) is recommended as first-line therapy 1, 2
- For patients with acute ischemic syndromes involving the vertebral artery territory and angiographic evidence of thrombus in the extracranial portion, anticoagulation is recommended for at least 3 months, whether or not thrombolytic therapy is used initially 3, 1
- The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo (5.7% vs 10.8%) 1, 2
- Ticlopidine has demonstrated superiority to aspirin for secondary prevention of ischemic events in patients with symptomatic posterior circulation disease 3, 4
Revascularization Options
Surgical Management
- Surgical interventions are rarely performed for vertebral artery disease and should be considered only when medical therapy fails to control symptoms 3, 2
- Surgical approaches include:
- For proximal vertebral artery reconstruction, early complication rates range from 2.5% to 25% with perioperative mortality rates of 0% to 4% 3, 1
Endovascular Management
- Endovascular treatment (angioplasty and stenting) carries risks including death (0.3%), periprocedural neurological complications (5.5%), and posterior stroke (0.7%) at mean follow-up of 14.2 months 3, 1
- Restenosis occurs in approximately 26% of proximal vertebral artery interventions after a mean of 12 months 3, 1, 2
- There is little evidence from randomized trials that endovascular management is superior to best medical management 3
- Endovascular angioplasty with stenting can be considered for severe cases where the stump of the artery ostium is not visualized but the distal patent artery is reconstituted via collateral circulation 5
Special Considerations
- When both vertebral arteries are patent and one has a significant stenotic lesion, the contralateral vertebral artery usually supplies sufficient blood flow to the basilar artery, provided there is anatomic continuity 1
- For patients with vertebral artery dissection, which can be a cause of collapse, anticoagulation or antiplatelet therapy is recommended if surgical management is not indicated 6, 7
- In cases of traumatic vertebral artery injuries with active hemorrhage, surgical intervention and vertebral artery ligation may be necessary 8
- Monitoring for recurrent symptoms and considering serial noninvasive imaging to assess progression is recommended 1, 2
Pitfalls and Caveats
- Vertebral artery collapse can be easily missed in patients with mild trauma or non-specific symptoms, leading to delayed diagnosis and treatment 6
- The annual stroke risk after angioplasty for distal vertebrobasilar disease is approximately 3%, with rates of stroke and restenosis related to more distal and anatomically complex lesions 3
- Despite anticoagulation therapy, patients with vertebral artery injuries may still become symptomatic (5.8%) or die due to cerebrovascular ischemia (2.9%) 9
- Percutaneous transcatheter embolization for vertebral artery pseudoaneurysms or arteriovenous fistulas can cause transient posterior circulation ischemia 8