What is the management approach for vertebral artery occlusive symptoms?

Management of Vertebral Artery Occlusive Symptoms

The management of vertebral artery occlusive symptoms should follow a stepwise approach, with antiplatelet therapy as first-line treatment, followed by consideration of revascularization only when medical therapy fails to control symptoms. 1, 2

Diagnostic Evaluation

• MRA or CTA is recommended over ultrasound for evaluation of vertebral arteries in patients with symptoms of posterior cerebral or cerebellar ischemia due to higher diagnostic accuracy (94% vs 70% sensitivity) 1, 2
• Catheter-based contrast angiography is useful when noninvasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization 3, 2
• Serial noninvasive imaging of the extracranial vertebral arteries is reasonable to assess progression of atherosclerotic disease and exclude development of new lesions 3, 2

Medical Management

First-line Treatment

• Antiplatelet therapy is the cornerstone of management for vertebral artery occlusive disease 1, 2
• Aspirin (75-325 mg daily) is recommended as first-line antiplatelet therapy 1, 2
• For patients with aspirin contraindications, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 3, 2
• The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo 3, 1

Special Circumstances

• For patients with acute ischemic syndromes involving the vertebral artery territory with angiographic evidence of thrombus in the extracranial portion, anticoagulation is recommended for at least 3 months 3, 1
• Risk factor modification should follow the same guidelines as for extracranial carotid atherosclerosis 2

Revascularization Options

Surgical Management

• Surgical intervention should be considered when medical therapy fails to control symptoms 2

• Surgical approaches for proximal vertebral artery reconstruction include: 3

  • Trans-subclavian vertebral endarterectomy
  • Transposition of the vertebral artery to the ipsilateral common carotid artery
  • Reimplantation of the vertebral artery with vein graft extension to the subclavian artery

• For proximal vertebral artery reconstruction, early complication rates range from 2.5% to 25% with perioperative mortality rates of 0% to 4% 3, 1

• For distal vertebral artery reconstruction, mortality rates range from 2% to 8% 3

Endovascular Management

• Endovascular treatment (angioplasty and stenting) is technically feasible but carries risks, including: 3, 1, 4

  • Death (0.3%)
  • Periprocedural neurological complications (5.5%)
  • Posterior stroke (0.7%)

• Restenosis occurs in approximately 26% of proximal vertebral artery interventions, typically within the first 6-12 months 3, 1, 4

• There is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management 3

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 3, 1
• For patients with subclavian steal syndrome, extra-anatomic carotid-subclavian bypass is recommended in the absence of clinical factors predisposing to surgical morbidity 1, 2
• Positional vertebral artery occlusion, where the artery is occluded or recanalized based on neck position, may require special consideration and dynamic evaluation 5

Follow-up and Monitoring

• Serial noninvasive imaging of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization 3, 2
• Monitoring for recurrent symptoms is essential, particularly in the first year after intervention 2, 4

Clinical Pitfalls and Caveats

• The mortality risk in vertebral artery occlusion is not negligible (reported as high as 25% in some series), contrary to common belief 6
• Vertebral artery occlusive disease is common in patients with posterior circulation ischemia (20% in one registry), but is often associated with other potential mechanisms of stroke 7
• In-stent stenosis appears most commonly during the first 6-12 months after stent placement but does not always correlate with return of neurological symptoms 4