Vertebral Artery Stenosis
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(2020) 22:35
Cerebrovascular Disease and Stroke (S Silverman, Section Editor)
Vertebral Artery Stenosis Daniel C. Brooks, MD1 Joseph L. Schindler, MD2,* Address 1 Department of Internal Medicine, Division of Neurology, Stamford Health Medical Group and Stamford Hospital, Stamford, CT, USA *,2 Department of Neurology, Yale University School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Cerebrovascular Disease and Stroke Keywords Vertebral artery stenosis I Vertebrobasilar stenosis I Posterior circulation I Stroke I TIA
Abstract Purpose of review Vertebral artery stenosis is a common condition associated with a very high risk of stroke. The goal of this review is to summarize the pathophysiology and natural history of vertebral artery stenosis and to evaluate the efficacy of medical and endovascular therapies. Recent findings Early and aggressive initiation of medical care combined with advancements in antithrombotic and lipid-lowering therapies has substantially reduced the risk of stroke due to vertebral artery stenosis. Endovascular therapy does not appear to be beneficial with extracranial vertebral artery stenosis and appears harmful with intracranial vertebral artery stenosis. Summary Risk of stroke due to symptomatic vertebral artery stenosis can be significantly reduced with implementation of standardized best medical therapy protocols focusing on ultra-early dual antiplatelet therapy, high-intensity statin therapy + novel lipid-lowering agents, and aggressive risk factor control. Endovascular therapy with angioplasty and stenting is not likely to play a significant role in treatment.
Introduction About 20% of ischemic strokes occur in the posterior circulation, a large cerebrovascular territory supplied by the vertebral arteries (VAs) which includes the brainstem, cerebellum, and inferior/posterior cerebral hemispheres [1]. Vertebrobasilar stenosis—of which atherosclerosis is by far the most common cause—is responsible for about 25–33% of ischemic strokes in the posterior circulation [2, 3]. Symptomatic VA stenosis is a high-risk condition
compared with other ischemic stroke subtypes, associated with a perhaps threefold higher risk of recurrent stroke than small vessel disease or cardioembolism [4]. Multiple factors increase risk of stroke with VA stenosis. First, atherosclerosis appears to be a higher risk condition than other causes of VA stenosis such as dissection [4, 5]. Second, intracranial involvement of the disease process, whether atherosclerosis or dissection, is typically more
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Curr Treat Options Cardio Med
severe than extracranial involvement [4]. Third, the risk of ischemic stroke increases with the degree of VA stenosis. In patients with atherosclerosis, VA stenosis 9 50% is associated with a much higher risk of ischemic stroke than stenosis G 50% or no stenosis at all [6]. Fourth, ischemic stroke risk i
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