What is the management for a left vertebral artery occlusion?

Management of Left Vertebral Artery Occlusion

Medical management with antiplatelet therapy is the primary treatment for vertebral artery occlusion, with revascularization reserved only for patients who fail medical therapy and have recurrent ischemic symptoms. 1

Acute Presentation: Distinguish Between Acute Thrombotic Occlusion vs. Chronic Occlusion

If Acute Basilar Artery Occlusion (BAO) with Symptoms

• Mechanical thrombectomy is indicated within 12 hours if NIHSS ≥6, PC-ASPECTS ≥6, age 18-89 years 1
• Thrombectomy is reasonable between 12-24 hours from last known well with same criteria 1
• Beyond 24 hours, consider thrombectomy on case-by-case basis, though outcomes are universally poor with NIHSS ≤6 1

If Extracranial Vertebral Artery Occlusion with Thrombus

• Anticoagulation with heparin followed by warfarin for at least 3 months is recommended when angiographic evidence of thrombus is present in the extracranial vertebral artery 2, 3
• This applies whether or not thrombolytic therapy is used initially 2

Chronic/Stable Vertebral Artery Occlusion: Medical Management First-Line

Antiplatelet Therapy (Primary Treatment)

• Aspirin 75-325 mg daily as first-line therapy 2, 4
• Clopidogrel 75 mg daily if aspirin contraindicated 4
• Aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke/TIA compared to placebo 2, 4

When Contralateral Vertebral Artery is Patent

• Medical management alone is typically sufficient when the contralateral vertebral artery is patent and dominant, as it usually provides adequate basilar artery perfusion 1, 2
• The key exception is if atheroembolism from the occluded vessel is causing recurrent brainstem or cerebellar infarction 1

Revascularization: Only After Medical Therapy Fails

Indications for Intervention

• Persistent or recurrent posterior circulation ischemic symptoms despite optimal medical therapy 4, 3
• Symptoms must be clearly attributable to the vertebral artery occlusion 1

Endovascular Treatment (Preferred if Intervention Needed)

• Angioplasty and stenting are technically feasible but carry significant risks: 1, 2
  • Death: 0.3%
  • Periprocedural neurological complications: 5.5%
  • Posterior stroke: 0.7%
  • Restenosis: 26% at mean 12-month follow-up 2, 4
• No randomized trial has demonstrated superiority of endovascular treatment over medical management 1

Surgical Treatment (Rarely Performed)

• Surgical options include trans-subclavian vertebral endarterectomy, vertebral artery transposition to common carotid artery, or reimplantation with vein graft 1, 2, 4
• Proximal vertebral artery reconstruction: complication rates 2.5-25%, perioperative mortality 0-4% 1, 2
• Distal vertebral artery reconstruction: mortality rates 2-8% 1
• Surgery may be effective when symptoms are clearly attributable to vertebral artery disease and medical therapy has failed 1

Critical Diagnostic Requirements Before Any Intervention

Imaging Protocol

• MRA or CTA (94% sensitivity) rather than ultrasound (70% sensitivity) for initial evaluation 2, 3
• Catheter-based contrast angiography is required before revascularization, as neither MRA nor CTA reliably delineates vertebral artery origins 2, 4
• Consider dynamic angiography if rotational vertebral artery occlusion is suspected (symptoms with head turning) 5, 6

Special Clinical Scenarios

Traumatic Vertebral Artery Occlusion

• Anticoagulation with heparin then warfarin for at least 3 months 3
• After 3-6 months, transition to long-term antiplatelet therapy 3
• Anatomic healing occurs in 72-100% of dissection cases 3

Bilateral Vertebral Artery Occlusion

• High mortality risk (25% in historical series) and may cause rapid fatal ischemic damage to cerebellum and brainstem 7, 8
• Requires urgent evaluation and aggressive management 7

Critical Pitfalls to Avoid

• Do NOT use dual antiplatelet therapy (aspirin + clopidogrel) routinely - hemorrhage risk outweighs benefit 3
• Do NOT rely on ultrasound alone for vertebral artery evaluation - sensitivity too low at 70% 3
• Do NOT pursue revascularization as first-line therapy - insufficient evidence of benefit over medical management 1, 4
• Do NOT miss bilateral or dominant vertebral artery occlusion - these carry significantly higher mortality risk 7, 8

Long-Term Management

• Continue indefinite antiplatelet therapy after acute phase 3
• Aggressive cardiovascular risk factor modification: lipid management, blood pressure control, smoking cessation 3
• Monitor for recurrent symptoms and consider serial noninvasive imaging to assess disease progression 4