Vertebral Artery Stenosis: A Narrative Review

Abstract

Vertebral artery stenosis (VAS) is the cause of approximately 20% of ischemic strokes in the posterior circulation. There are several causes of vertebral artery stenosis, including atherosclerosis, calcification, dissections, fibromuscular dysplasia, giant cell arteritis, neurofibromatosis type 1, and bony compressions. The most common cause of VAS is atherosclerosis which is derived from the macrophage-induced oxidation of low-density lipoproteins (LDLs), alongside the accumulation of cholesterol. Calcification of the vertebral artery occurs when there is excess calcium and phosphate deposition in the vessel. Dissection of the vertebral artery can lead to the formation of a hematoma causing stenosis of the vertebral artery. Fibromuscular dysplasia can result in stenosis due to the deposition of collagen fibers in the tunica media, intima, or adventitia. Giant cell arteritis, an autoimmune disorder, causes inflammation of the internal elastic membrane resulting in eventual stenosis of the artery. Neurofibromatosis type 1, an autosomal dominant disorder, results in the stenosis of the vertebral artery due to the altered function of neurofibromin. Mechanical compression of the vertebral artery by bone can also cause stenosis of the vertebral artery. Digital subtraction angiography (DSA) is considered the current gold standard in diagnosing vertebral artery stenosis; however, its associated morbidity and mortality have led to increased use of noninvasive techniques such as duplex ultrasonography (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Currently, asymptomatic and symptomatic vertebral artery stenoses are treated by risk factor modification and medical treatment. However, it is recommended that surgical (endarterectomy, reconstruction, and decompression) and endovascular (balloon coronary, baremetal, and drug-eluting stents) treatments are also used for symptomatic vertebral artery stenosis.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

“…Diabetes mellitus, hypertension, and hyperlipidemia are common risk factors for VAS (Zhang et al, 2017). If not treated in time, it may lead to stroke, Subclavian Steal Syndrome, myocardial infarction, vertebrobasilar insufficiency and even sudden death (Burle et al, 2022). Patients with VAS have a higher risk of recurrent stroke compared with patients with carotid artery stenosis (Xu et al, 2022) and VAS ≥ 50 % is a strong independent predictor of recurrent stroke (Zhang et al, 2017).…”

“…(Searls et al, 2012). If VAS is left undiagnosed and unmanaged,it increases the risk of diseases such as cerebrovascular accidents, myocardial infarction and sudden death (Burle et al, 2022), so it is important to accurately evaluate the degree of VAS in patients, and to grasp the hemodynamic characteristics of patients.…”

Ischaemic stroke in a patient with non-valvular atrial fibrillation (NVAF) despite non-vitamin K oral anticoagulant (NOAC) therapy

“…Intracranial atherosclerosis can be evaluated with conventional angiogram, MR angiogram (MRA), CTA and/or transcranial Doppler; optimal management of intracranial atherosclerosis currently remains an area of debate but includes medical management and/or angioplasty/stent 21. Extracranial vertebral artery atherosclerosis can be evaluated with digital subtraction angiography versus duplex ultrasonography, CTA or MRA; management includes medical, surgical and/or endovascular strategies 22. All plans should include continuous lifelong vascular risk factor optimisation via sustained behavioural modifications (physical activity, diet and nutrition, smoking cessation) and intensive medical therapy as per the 2014 AHA/ASA (American Stroke Association) guidelines 23.…”

The Role of High-Resolution Magnetic Resonance Imaging in Cerebrovascular Disease: A Narrative Review

“…These methods are essential for the accurate diagnosis of cerebrovascular diseases. While DSA remains the gold standard for assessing carotid artery stenosis [ 77 , 78 ], its invasive nature poses a risk to patients. Conventional imaging techniques focus on the vascular lumen, patency, and stenosis, with conventional MR indirectly assessing the degree of lumen stenosis by measuring blood flow velocity.…”