Treatment for Bilateral Vertebral Artery Occlusion
Diagnostic Approach
- MRA or CTA is recommended over ultrasound for evaluation of vertebral arteries in patients with suspected posterior cerebral or cerebellar ischemia due to higher diagnostic accuracy (94% vs 70% sensitivity) 1, 3
- Catheter-based contrast angiography is useful when noninvasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization 1, 3
- Serial noninvasive imaging of the extracranial vertebral arteries is reasonable to assess progression of atherosclerotic disease and exclude development of new lesions 2, 3
Medical Management
- The American College of Cardiology recommends antiplatelet therapy as the cornerstone of management, with aspirin (75-325 mg daily) as first-line therapy 1, 4
- For patients with aspirin contraindications, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 2, 3
- The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo 1, 5
- Anticoagulation is recommended for at least 3 months for patients with acute ischemic syndromes involving the vertebral artery territory with angiographic evidence of thrombus in the extracranial portion 1, 5
- The American College of Cardiology recommends medical therapy and lifestyle modification to reduce atherosclerotic risk according to the standards for extracranial carotid atherosclerosis 4, 7
Revascularization Options
- Revascularization should be considered when medical therapy fails to control symptoms 2
- Surgical approaches for proximal vertebral artery reconstruction include transposition of the vertebral artery to the ipsilateral common carotid artery and reimplantation of the vertebral artery with vein graft extension to the subclavian artery 1, 5
- Endovascular treatment (angioplasty and stenting) carries risks, including death (0.3%), periprocedural neurological complications (5.5%), and posterior stroke (0.7%) 1, 5
- Restenosis occurs in approximately 26% of proximal vertebral artery interventions 1, 2
Special Considerations
- The American College of Cardiology recommends extra-anatomic carotid-subclavian bypass for subclavian steal syndrome in the absence of clinical factors predisposing to surgical morbidity 2, 7
- Percutaneous endovascular angioplasty and stenting is reasonable for patients with symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis who are at high risk of surgical complications 7