Management of Vertebral Artery Occlusion

Acute Presentation Management

The American College of Cardiology recommends mechanical thrombectomy within 12 hours if 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
For acute ischemic syndromes with angiographic evidence of thrombus in the extracranial vertebral artery, anticoagulation with heparin followed by warfarin is recommended for at least 3 months, regardless of whether thrombolytic therapy is used initially 2, 1

Aspirin 75-325 mg daily is first-line therapy for vertebral artery occlusion 1
The combination of aspirin plus extended-release dipyridamole (200 mg twice daily) reduced vertebrobasilar territory stroke/TIA from 10.8% to 5.7% compared to placebo 2, 1
Ticlopidine 250 mg twice daily was superior to aspirin for secondary prevention in symptomatic posterior circulation disease 2

MRA or CTA is required over ultrasound for initial evaluation, with 94% sensitivity versus 70% for ultrasound 1, 3
Catheter-based contrast angiography is mandatory before any revascularization procedure, as neither MRA nor CTA reliably delineates vertebral artery origins 1, 3

Revascularization should only be pursued after medical therapy fails in patients with persistent or recurrent posterior circulation ischemic symptoms despite optimal medical management 1, 3
Endovascular treatment carries a 0.3% death risk, 5.5% periprocedural neurological complication risk, and 0.7% posterior stroke risk at 14.2 months follow-up 2, 1
Restenosis occurs in 26% of proximal vertebral artery interventions at mean 12-month follow-up, though not consistently correlated with recurrent symptoms 2, 1

Surgical approaches include trans-subclavian vertebral endarterectomy, transposition of the vertebral artery to the ipsilateral common carotid artery, and reimplantation with vein graft extension to the subclavian artery 2, 4
For proximal vertebral artery reconstruction, early complication rates range from 2.5% to 25% with perioperative mortality of 0% to 4% 2, 4

Anticoagulation with heparin then warfarin for at least 3 months is recommended for traumatic vertebral artery occlusion 1
Anatomic healing occurs in 72-100% of dissection cases 1

Do not use dual antiplatelet therapy (aspirin + clopidogrel) routinely—hemorrhage risk outweighs benefit 1
Do not pursue revascularization as first-line therapy—insufficient evidence of benefit over medical management exists 1, 3

Continue indefinite antiplatelet therapy after the acute phase with aggressive cardiovascular risk factor modification 1, 3
Serial noninvasive imaging of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization to assess disease progression and exclude new lesions 3
Monitor continuously for recurrent symptoms, as atheroembolism from vertebral artery origin lesions may cause brainstem or cerebellar infarction even when the contralateral vertebral artery is patent 2