From the Guidelines
The left vertebral artery with chronic high-grade narrowing at its origin due to focal atherosclerosis should be managed with medical therapy, including antiplatelet agents such as aspirin 81mg daily or clopidogrel 75mg daily, and a statin like atorvastatin 40-80mg daily, along with lifestyle modifications and regular follow-up imaging. Given the anatomically dominant nature of the left vertebral artery, it is crucial to prioritize its perfusion to prevent vertebrobasilar insufficiency. The management strategy should focus on reducing systemic atherosclerotic risk and preventing ischemic complications, as outlined in guidelines for carotid artery disease management 1. Blood pressure control, aiming for levels below 140/90 mmHg, is also essential in managing this condition. Lifestyle modifications including smoking cessation, regular exercise, and a heart-healthy diet are crucial components of treatment. Regular follow-up imaging with ultrasound or CT angiography every 6-12 months is recommended to monitor for disease progression. If symptoms of vertebrobasilar insufficiency develop (dizziness, vertigo, visual disturbances) or if stenosis progresses significantly, endovascular intervention may be considered, taking into account the latest guidelines on aortic disease management 1. This approach addresses the atherosclerotic disease while recognizing the importance of the dominant left vertebral artery in cerebral blood supply. Key considerations include the potential need for revascularization to maintain perfusion through the posterior circulation via the left vertebral artery, especially in the context of planned interventions that might compromise its flow. However, the decision for such interventions should be made on a case-by-case basis, considering the patient's overall risk profile and the potential benefits and risks of the procedure.
From the Research
Atherosclerotic Vertebral Artery Disease
- The left vertebral artery origin chronic high-grade chronic narrowing secondary to short-segment focal atherosclerosis is consistent with the findings of 2, which states that atherosclerotic lesions are very common at the origin and first few centimeters of the vertebral artery in the neck.
- The anatomically dominant left vertebral artery noted is also consistent with the study by 3, which found that the left subclavian artery had a significantly higher prevalence of atherosclerotic plaque than the right corresponding artery.
- The distal V4 short-segment nonocclusive minimal punctate barely perceptible atherosclerotic and soft plaque creating no appreciable narrowing is consistent with the findings of 2, which states that patients with nonstenosing vertebral artery plaques should be treated with statins and antiplatelet agents.
Treatment Options
- The use of antiplatelet agents and anticoagulants in the treatment of arteriosclerosis is well established, based on many large randomized trials, as stated in 4.
- Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease, as stated in 5.
- Aspirin has long been recognized as a beneficial treatment for atherosclerotic cardiovascular disease due to its antiplatelet effects, as stated in 6.
Plaque Characteristics
- The characteristics of atherosclerotic plaque, including plaque type, plaque surface morphology, plaque distribution, location of calcified nodules, and plaque thickness, vary in different segments, sides, and between anterior and posterior circulation stroke, as stated in 3.
- The left subclavian artery had a higher prevalence of mixed plaque and noncalcified plaque, and a lower prevalence of calcified plaque, than the right corresponding artery, as stated in 3.