Published online before print September 9, 2004, doi: 10.1161/01.STR.0000143732.94767.e8
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(Stroke. 2004;35:2433.)
© 2004 American Heart Association, Inc.
Letters to the Editor |
The Often-Neglected Vertebral Artery
Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, Pa
Drexel University College of Medicine, Philadelphia, Pa
To the Editor:
The SSYLVIA trial’s results clearly add to the nascent body of literature evaluating vertebral artery stenting.1 Even in the absence of ’gold standard’ surgical procedures such as endarterectomy for the treatment for vertebral artery disease, the recognition of vertebral artery disease has not progressed like its carotid artery counterpart. Rocha-Singh insightfully attributed this to the nonspecific symptoms associated with posterior cerebral ischemia, difficulties imaging proximal vertebral artery stenosis with ultrasound, and the absence of a standard surgical therapy for vertebral artery disease.2
The relationship between vertebral artery insufficiency and posterior circulation ischemia is now becoming clear. In a review over 400 cases evaluated for posterior circulation stroke or transient ischemic attack, Wityk et al determined that 20% of patients with posterior ischemia had occlusive disease in the proximal vertebral artery (V1 segment); in 9% of patients a lesion in the V1 segment was the only defined cause of stroke.3 Similarly, the role of vertebral artery disease and other neurological pathologies is now better understood (ie, the relationship between isolated vertigo without other neurological symptoms and vertebral insufficiency). Welsh et al found in a review of patients suffering from long-standing vertigo that 52% of patients demonstrated abnormal configurations or diminished vertebrobasilar flow, 76% of these having the pathology of the vertebral artery.4
Magnetic resonance technology has been used successfully to noninvasively identify vertebral artery disease.5 Similarly, vertebral artery stenting has demonstrated successful procedural outcomes in case series and in this before-mentioned trial.1,2 There should be an increased awareness of the relationship between posterior ischemia and vertebral artery disease, the absence of an acceptable surgical treatment, and the potential vertebral artery stent-supported angioplasty may offer. Ultimately, large-scale randomized trials are necessary to accurately determine the future role of stent-supported angioplasty in the long-term management of vertebral artery disease.
References
1. The SSYLVIA Study Investigators. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 2004; 35: 1388–1392.
2. Rocha-Singh K. Vertebral artery stenting: ready for prime time? Catheter Cardiovasc Interv. 2001; 54: 6–7.[CrossRef][Medline] [Order article via Infotrieve]
3. Wityk RJ, Chang HM, Rosengart A, Han W, DeWitt D, Pessin MS, Caplan LR. Proximal extracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 1998; 55: 470–478.
4. Welsh LW, Welsh JJ, Lewin B. Vertigo: analysis by magnetic resonance imaging and angiography. Ann Otol Rhinol Laryngol. 2000; 109: 39–48.
5. Fujita N, Yamanaka T, Hosoi H. Usefulness of MR angiography in cases of central vertigo. Auris Nasus Larynx. 2002; 29: 247–252.[Medline] [Order article via Infotrieve]
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