Incidence and prognosis of >=50% symptomatic vertebral or basilar artery stenosis: prospective population-based study

Abstract

The higher risk of early recurrent stroke after posterior circulation transient ischaemic attack or minor stroke versus after carotid territory events could be due to a greater prevalence of large artery stenosis, but there have been few imaging studies, and the prognostic significance of such stenoses is uncertain. Reliable data are necessary to determine the feasibility of trials of angioplasty and stenting and to inform imaging strategies. In the first-ever population-based study, we determined the prevalence of > or = 50% apparently symptomatic vertebral and basilar stenosis using contrast-enhanced MRA in consecutive patients, irrespective of age, presenting with posterior circulation transient ischaemic attack or minor ischaemic stroke in the Oxford Vascular Study and related this to the 90-day risk of recurrent transient ischaemic attack and stroke. For comparison, we also determined the prevalence of > or = 50% apparently symptomatic carotid stenosis on ultrasound imaging in consecutive patients with carotid territory events. Of 538 consecutive patients, 141/151 (93%) had posterior circulation events and had vertebral and basilar imaging, of whom 37 (26.2%) had > or = 50% vertebral and basilar stenosis, compared with 41 (11.5%) patients with > or = 50% ipsilateral carotid stenosis in 357/387 (92%) patients with carotid events who had carotid imaging (OR = 2.74; 95% CI = 1.67-4.51; P = 0.002). Presence of > or = 50% vertebral and basilar stenosis was unrelated to age, sex or vascular risk factors and, in contrast to > or = 50% carotid stenosis was not associated with evidence of coronary/peripheral atherosclerosis. In patients with posterior circulation events, > or = 50% vertebral and basilar stenosis was associated multiple transient ischaemic attacks at presentation (22% versus 3%; OR = 9.29; 95% CI = 2.31-37.27; P < 0.001) and with a significantly higher 90-day risk of recurrent events (OR = 3.2; 95% CI = 1.4-7.0; P = 0.006), reaching 22% for stroke and 46% for transient ischaemic attack and stroke. The prevalence of > or = 50% vertebral and basilar stenosis in posterior circulation transient ischaemic attack or minor stroke is greater than the prevalence of > or = 50% carotid stenosis in carotid territory events, and is associated with multiple transient ischaemic attacks at presentation and a high early risk of recurrent stroke. Trials of interventional treatment are therefore likely to be feasible, but more data are required on the long-term risk of stroke on best medical treatment.

Duplex ultrasonography for the detection of vertebral artery stenosis

“…we found approximately the same prevalence of significant vertebral artery stenosis with CTA (Caplan et al, 2004;Marquardt et al, 2009). …”

“…Vertebrobasilar stenosis is an important cause of posterior circulation stroke and is found in 26.2% patients with such stroke (Marquardt, Kuker, Chandratheva, Geraghty, & Rothwell, 2009). In addition, the presence of vertebrobasilar stenosis is known to double or triple the risk of a recurrent posterior circulation stroke (Gulli, Khan, & Markus, 2009;Marquardt et al, 2009). …”

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

“…[300][301][302][303] A study using contrast-enhanced MRA in consecutive patients with posterior circulation TIA or minor stroke found a prevalence of >50% vertebral and basilar arterial stenosis, and vertebrobasilar arterial stenosis was more often associated with multiple ischemic episodes and a higher risk of early recurrent stroke. 304 …”

Posterior cerebral circulation re-visited: vertebral artery surgery

“…Girişimsel tedavi ve en iyi medikal tedavi ile ilgili daha çok çalışmaya ihtiyaç vardır. [22] Çalışmamızda ilgi çeken bir diğer konu, hastalarda yüksek oranda hiperlipidemi olmasıdır (Tablo 1). Her ne kadar çok yüksek bir oranda prevalans varsa da, hasta sayısı daha ileri sonuçlara varmamız için yeterli değildir.…”