Who should be consulted first for a patient with vertebral artery occlusion?

Consultation for Vertebral Artery Occlusion

A patient with vertebral artery occlusion should be immediately evaluated by a neurologist or stroke specialist, with vascular neurology or neurointerventional consultation for consideration of acute revascularization if presenting within 24 hours of symptom onset. 1, 2

Acute Presentation (Within 24 Hours)

Immediate neurologist/stroke team consultation is mandatory for patients presenting with acute posterior circulation symptoms including dizziness, vertigo, diplopia, ataxia, bilateral sensory deficits, or altered mental status. 3, 4, 2

Critical Early Actions:

• Neurointerventional specialist consultation should occur simultaneously with initial neurological assessment, as mechanical thrombectomy can be performed up to 24 hours from symptom onset in vertebrobasilar occlusions. 1
• Intravenous thrombolysis (rt-PA) and intra-arterial thrombolysis are the primary treatment approaches, with recanalization significantly improving morbidity and mortality. 2
• Vigilance for early recurrent stroke is essential, as vertebral artery stump syndrome can cause fatal recurrent basilar artery occlusion within hours despite initial successful treatment. 5

Subacute/Chronic Presentation

For patients with established vertebral artery occlusion or chronic symptoms, a vascular neurologist should coordinate care, with additional consultations based on imaging findings and treatment plans. 3

Multidisciplinary Team Involvement:

Vascular Neurology (primary consultant):

• Manages medical therapy including antiplatelet agents and anticoagulation when thrombus is present. 3
• Coordinates risk factor modification and surveillance imaging. 3, 6

Neuroradiology/Interventional Neuroradiology:

• Required for catheter-based contrast angiography before any revascularization procedure, as neither MRA nor CTA reliably delineates vertebral artery origins. 3, 4
• Performs endovascular interventions if medical therapy fails, though this carries 5.5% periprocedural neurological complication risk and 0.3% mortality. 3, 6

Vascular Surgery/Neurosurgery:

• Consulted only for rare surgical reconstruction cases, as operations are rarely performed for vertebral artery occlusive disease with mortality rates of 0-4% for proximal and 2-8% for distal reconstruction. 3, 6
• May be needed for rotational vertebral artery occlusion requiring surgical decompression at C2 level. 7

Diagnostic Pathway Before Consultation

Initial imaging with CTA or contrast-enhanced MRA (94% sensitivity and 95% specificity) should be obtained rather than ultrasound (70% sensitivity) to guide specialist consultation. 3, 4, 6

High-Risk Patients Requiring Screening:

• Asymptomatic bilateral carotid occlusions mandate vertebral artery evaluation. 3, 4
• Unilateral carotid occlusion with incomplete circle of Willis requires screening for vertebral artery disease. 3, 4

Common Pitfalls to Avoid

Do not delay consultation for "complete workup" - vertebrobasilar occlusion requires urgent specialist evaluation as the therapeutic window extends to 24 hours. 1, 2

Do not assume symptoms are benign vestibular disease - dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, and syncope can all represent vertebral artery occlusion and require neurological assessment. 3, 4

Do not miss rotational component - symptoms provoked by head turning require dynamic angiography to identify the correct occlusion site, as static imaging may miss or misdiagnose the lesion. 7

Do not withhold antithrombotic therapy after acute intervention - vertebral artery stump syndrome can cause fatal recurrent basilar occlusion within 13 hours despite initial successful treatment. 5