Opinion statement
Stenosis of the vertebral artery (VA) in either its extra- or intracranial portions is an important cause of posterior circulation stroke. Diagnosis of VA stenosis by noninvasive imaging techniques is improving and new endovascular and medical treatments are now available. However, the natural history of VA stenotic lesions is not known and its optimum management is unclear. Symptomatic VA stenosis should be initially treated with established antiplatelet agents. There is no proven indication for anticoagulation in cases of VA stenosis. Case series have shown that angioplasty and stenting for proximal extracranial VA stenosis have a low perioperative complication rate and are effective in restoring luminal diameter. Evidence from randomized trials on its long-term efficacy versus medical therapy is not available. Regarding current evidence where symptoms are refractory to antiplatelet treatment, or where recurrent stroke risk is considered increased due to either an incomplete circle of Willis or an anomalous VA circulation, it can be considered in centers with experience of the procedure. Randomized trials comparing stenting with medical therapy are required. Surgery may be a viable alternative to angioplasty and stenting, but only in a few specialist centers. Evidence from randomized controlled trials of medical and other interventions for VA stenosis are required.
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References and Recommended Reading
Bamford J, Sandercock P, Dennis M, et al.: Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991, 337:1521–1526.
Bogousslavsky J, Van Melle G, Regli F: The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke 1988, 19:1083–1092.
Caplan LR, Amarenco P, Rosengart A, et al.: Embolism from vertebral artery origin occlusive disease. Neurology 1992, 42:1505–1512.
Cloud GC, Markus HS: Diagnosis and management of vertebral artery stenosis. QJM 2003, 96:27–54. This is a more detailed review of the anatomy, natural history, and role of imaging in diagnosis and treatments for VA stenosis.
Qureshi AI, Ziai WC, Yahia AM, et al.: Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: a multicenter study. Neurosurgery 2003, 52:1033–1039. Discusses what is known of the natural history of ICVA stenosis and its implications for proposed new endovascular interventions.
Wityk RJ, Chang HM, Rosengart A, et al.: Proximal extracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol 1998, 55:470–478.
Moufarrij NA, Little JR, Furlan AJ, et al.: Basilar and distal vertebral artery stenosis: long-term follow-up. Stroke 1986, 17:938–942.
Akins PT, Pilgram TK, Cross DT 3rd, Moran CJ: Natural history of stenosis from intracranial atherosclerosis by serial angiography. Stroke 1998, 29:433–438.
Benesch CG, Chimowitz MI: Best treatment for intracranial arterial stenosis? 50 years of uncertainty. The WASID Investigators. Neurology 2000, 55:465–466.
Mohr JP, Thompson JL, Lazar RM, et al.: A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001, 345:1444–1451.
A randomized trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin. The Stroke Prevention in Reversible Ischemia Trial (SPIRIT) Study Group [no authors listed]. Ann Neurol 1997, 42:857–865.
Diener HC, Cunha L, Forbes C, et al.: European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996, 143:1–13.
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee [no authors listed]. Lancet 1996, 348:1329–1339.
Jneid H, Bhatt DL, Corti R, et al.: Aspirin and clopidogrel in acute coronary syndromes: therapeutic insights from the CURE study. Arch Intern Med 2003, 163:1145–1153.
Hacke W: From CURE to MATCH: ADP receptor antagonists as the treatment of choice for high-risk atherothrombotic patients. Cerebrovasc Dis 2002, 1(suppl 1):22–26.
Caplan LR: Atherosclerotic vertebral artery disease in the neck. Curr Treat Options Cardiovasc Med 2003, 5:251–256.
Bhatt DL, Kapadia SR, Bajzer CT, et al.: Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol 2001, 13:767–771.
Berguer R, Flynn LM, Kline RA, Caplan L: Surgical reconstruction of the extracranial vertebral artery: management and outcome. J Vasc Surg 2000, 31:9–18.
Kieffer E, Praquin B, Chiche L, et al.: Distal vertebral artery reconstruction: long-term outcome. J Vasc Surg 2002, 36:549–554.
Chaturvedi S, Fessler R: Angioplasty and stenting for stroke prevention: good questions that need answers. Neurology 2002, 59:664–668.
Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial [no authors listed]. Lancet 2001, 357:1729–1737.
Jenkins JS, Subramanian R: Endovascular treatment for vertebrobasilar insufficiency. Curr Treat Options Cardiovasc Med 2002, 4:385–391.
Cloud GC, Crawley F, Clifton A, et al.: Vertebral artery origin angioplasty and primary stenting: safety and restenosis rates in a prospective series. J Neurol Neurosurg Psychiatry 2003, 74:586–590. Single-center case series of PTA and stenting for symptomatic proximal ECVA stenosis with the longest published follow-up, highlighting problems of restenosis with PTA alone and making comparisons with other published series.
Jenkins JS, White CJ, Ramee SR, et al.: Vertebral artery stenting. Catheter Cardiovasc Interv 2001, 54:1–5.
Chastain HD 2nd, Campbell MS, Iyer S, et al.: Extracranial vertebral artery stent placement: in-hospital and followup results. J Neurosurg 1999, 91:547–552.
Mukherjee D, Roffi M, Kapadia SR, et al.: Percutaneous intervention for symptomatic vertebral artery stenosis using coronary stents. J Invasive Cardiol 2001, 13:363–366.
Piotin M, Spelle L, Martin JB, et al.: Percutaneous transluminal angioplasty and stenting of the proximal vertebral artery for symptomatic stenosis. AJNR Am J Neuroradiol 2000, 21:727–731.
Albuquerque FC, Fiorella D, Han P, et al.: A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis. Neurosurgery 2003, 53:607–614.
Gress DR, Smith WS, Dowd CF, et al.: Angioplasty for intracranial symptomatic vertebrobasilar ischemia. Neurosurgery 2002, 51:23–27; discussion 27–29.
Barakate MS, Snook KL, Harrington TJ, et al.: Angioplasty and stenting in the posterior cerebral circulation. J Endovasc Ther 2001, 8:558–565.
Levy EI, Hanel RA, Bendok BR, et al.: Staged stentassisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis. J Neurosurg 2002, 97:1294–1301.
Mori T, Kazita K, Mori K: Cerebral angioplasty and stenting for intracranial vertebral atherosclerotic stenosis. AJNR Am J Neuroradiol 1999, 20:787–789.
Mori T, Kazita K, Chokyu K, et al.: Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol 2000, 21:249–254.
Nahser HC, Henkes H, Weber W, et al.: Intracranial vertebrobasilar stenosis: angioplasty and follow-up. AJNR Am J Neuroradiol 2000, 21:1293–1301.
Rasmussen PA, Perl J 2nd, Barr JD, et al.: Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: an initial experience. J Neurosurg 2000, 92:771–778.
Chimowitz MI: Angioplasty or stenting is not appropriate as first-line treatment of intracranial stenosis. Arch Neurol 2001, 58:1690–1692.
Gomez CR, Orr SC: Angioplasty and stenting for primary treatment of intracranial arterial stenoses. Arch Neurol 2001, 58:1687–1690.
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Cloud, G.C., Markus, H.S. Vertebral artery stenosis. Curr Treat Options Cardio Med 6, 121–127 (2004). https://doi.org/10.1007/s11936-004-0040-5
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DOI: https://doi.org/10.1007/s11936-004-0040-5