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Vertebral artery stenosis
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of vertebral artery stenosis are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023), the European Society of Cardiology (ESC/ESVS 2018), and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011).
1
2
3
Screening and diagnosis
Diagnostic investigations
Vertebral artery imaging
As per ESVS 2023 guidelines:
Obtain CTA or contrast-enhanced MRA as first-line vascular imaging in patients with suspected vertebrobasilar ischemia.
B
Do not establish a diagnosis of vertebrobasilar ischemia (attributed to nipping of the vertebral arteries on head movement) in patients with vertigo or dizziness on head turning, unless corroborated by vascular imaging showing clear disruption of blood flow during head turning.
D
Diagnostic procedures
Catheter-based contrast angiography: as per AANN/AANS/ACC/…/SVS 2011 guidelines, consider obtaining catheter-based contrast angiography to define vertebral artery anatomy in patients with symptoms of posterior cerebral or cerebellar ischemia possibly being candidates for revascularization, when noninvasive imaging fails to define the location or severity of stenosis.
C
Medical management
Antiplatelet therapy: as per AANN/AANS/ACC/…/SVS 2011 guidelines, initiate antiplatelet therapy with aspirin 75-325 mg daily in patients with obstructive or nonobstructive atherosclerosis involving the extracranial vertebral arteries for the prevention of myocardial infarction and other ischemic cardiovascular events, but not for the prevention of stroke in asymptomatic patients.
A
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Management of hypertension
Management of dyslipidemia
Management of diabetes mellitus
Nonpharmacologic interventions
Therapeutic procedures
Specific circumstances
Follow-up and surveillance
Imaging follow-up
As per ESVS 2023 guidelines:
Do not obtain serial surveillance with catheter angiography in patients undergoing vertebral artery interventions.
D
Consider obtaining serial noninvasive imaging surveillance in patients who have undergone an open or endovascular vertebral artery intervention.
C