Management of Left Vertebral Artery Occlusion
Medical management with antiplatelet therapy is the primary treatment for left vertebral artery occlusion, with revascularization reserved only for patients who fail medical therapy and have recurrent posterior circulation ischemic symptoms. 1
Acute Presentation Management
Thrombectomy Criteria
- Mechanical thrombectomy is indicated within 12 hours if all of the following are met: NIHSS ≥6, PC-ASPECTS ≥6, and age 18-89 years 1
- Thrombectomy remains reasonable between 12-24 hours from last known well using the same criteria 1
Initial Medical Therapy
- Start antiplatelet therapy immediately as the cornerstone of acute management 1
- Aspirin 75-325 mg daily is first-line therapy 1
- If aspirin is contraindicated, use clopidogrel 75 mg daily 1
Chronic/Stable Vertebral Artery Occlusion
Standard Antiplatelet Regimen
- Aspirin 75-325 mg daily indefinitely is the recommended first-line therapy 1
- Clopidogrel 75 mg daily serves as an alternative when aspirin cannot be used 1
- Aspirin plus extended-release dipyridamole has demonstrated benefit in reducing vertebrobasilar territory stroke/TIA compared to placebo 1
Special Scenario: Traumatic Occlusion
- Anticoagulation with heparin followed by warfarin for at least 3 months is recommended for traumatic vertebral artery occlusion 1
- Anatomic healing occurs in 72-100% of dissection cases 1
Diagnostic Requirements Before Treatment Decisions
Imaging Hierarchy
- MRA or CTA (94% sensitivity) should be used rather than ultrasound (70% sensitivity) for initial evaluation 1
- Catheter-based contrast angiography is required before any revascularization procedure, as neither MRA nor CTA reliably delineates vertebral artery origins 1
Revascularization Approach
Indications (Strict Criteria)
- Revascularization should only be pursued after medical therapy fails in patients with persistent or recurrent posterior circulation ischemic symptoms despite optimal medical management 1
- This is not a first-line therapy due to insufficient evidence of benefit over medical management 1
Endovascular Treatment Risks
- Death occurs in 0.3% of cases 1
- Periprocedural neurological complications occur in 5.5% 1
- Restenosis develops in 26% at mean 12-month follow-up 1
- Endovascular treatment is preferred over surgical approaches if intervention is needed 1
Critical Pitfalls to Avoid
Medication Errors
- Do not use dual antiplatelet therapy (aspirin + clopidogrel) routinely, as hemorrhage risk outweighs benefit 1
Diagnostic Errors
- Do not rely on ultrasound alone for vertebral artery evaluation due to inadequate 70% sensitivity 1
Treatment Sequencing Errors
- Do not pursue revascularization as first-line therapy without attempting optimal medical management first 1
Long-Term Management Algorithm
Ongoing Monitoring
- Continue indefinite antiplatelet therapy after the acute phase 1
- Implement aggressive cardiovascular risk factor modification 1
- Monitor continuously for recurrent symptoms 1
- Consider serial noninvasive imaging to assess disease progression 2
Symptoms Requiring Urgent Re-evaluation
- Vertigo, diplopia, ataxia, bilateral sensory deficits, or syncope suggest posterior circulation ischemia 2
- Occipito-cervical headache often precedes cerebellar or medullary infarction 3
- Reproducible symptoms with head rotation suggest dynamic vertebral artery compression requiring dynamic angiography 4, 5