Management of Left Vertebral Artery Occlusion

Acute Presentation

The American Heart Association recommends medical management with antiplatelet therapy as the primary treatment for vertebral artery occlusion, with revascularization reserved only for patients who fail medical therapy and have recurrent ischemic symptoms 1, 2
Mechanical thrombectomy is indicated within 12 hours if NIHSS ≥6, PC-ASPECTS ≥6, age 18-89 years 3
Thrombectomy is reasonable between 12-24 hours from last known well with same criteria 3

The American College of Cardiology recommends aspirin 75-325 mg daily as first-line therapy for chronic vertebral artery occlusion 4, 6
Clopidogrel 75 mg daily is recommended if aspirin is contraindicated 6
Aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke/TIA compared to placebo 4, 6

The American Heart Association recommends revascularization only after medical therapy fails, in patients with persistent or recurrent posterior circulation ischemic symptoms despite optimal medical therapy 6, 5
Endovascular treatment is preferred if intervention is needed, but carries significant risks, including death (0.3%), periprocedural neurological complications (5.5%), and restenosis (26% at mean 12-month follow-up) 2, 4

The American College of Radiology recommends MRA or CTA (94% sensitivity) rather than ultrasound (70% sensitivity) for initial evaluation of vertebral artery occlusion 4, 5
Catheter-based contrast angiography is required before revascularization, as neither MRA nor CTA reliably delineates vertebral artery origins 4, 6

The American College of Cardiology recommends anticoagulation with heparin then warfarin for at least 3 months in cases of traumatic vertebral artery occlusion 5
Anatomic healing occurs in 72-100% of dissection cases 5

The American Heart Association recommends against using dual antiplatelet therapy (aspirin + clopidogrel) routinely, due to hemorrhage risk outweighing benefit 5
The American College of Radiology recommends against relying on ultrasound alone for vertebral artery evaluation, due to sensitivity too low at 70% 5
The American College of Cardiology recommends against pursuing revascularization as first-line therapy, due to insufficient evidence of benefit over medical management 2, 6

The American Heart Association recommends continuing indefinite antiplatelet therapy after acute phase, as well as aggressive cardiovascular risk factor modification and monitoring for recurrent symptoms 5, 6