David Goldemund M.D.
Updated on 07/11/2023, published on 16/12/2021

What is dolichoectasia?

  • a progressive disease characterized by elongation, dilation and tortuosity of the arteries, sometimes called dilated arteriopathy
    • the vertebrobasilar arteries are most commonly affected (also known as vertebrobasilar dolichoectasia or megadolichobasilar artery)
    • (pseudo)aneurysm, on the other hand, is characterized by a focal dilation, creating a weakened area prone to rupture
  • incidence 0.06-6% [Brutto, 2021]
  • associated with increased risk of stroke recurrence (up to 19%/2 years) [Chen, 2019]
    • likely cause of a fraction of strokes initially classified as cryptogenic [Brutto, 2021]
  • the following characteristics also apply to large fusiform aneurysms


dolichoectasia may lead to:

  • ischemic stroke through
    • thrombus formation (due to slowed flow)
      • occlusion of perforators
      • distal embolization
    • atherosclerotic plaques with stenosis or occlusion of penetrating (perforating) arteries

      • possible combination with thrombosis
    • distortion of the origin of the penetrating artery due to tortuosity
  • intracranial hemorrhage (ICH) or subarachnoid hemorrhage (SAH)
    • due to rupture of the fragile wall l (risk 20 times higher than in the general population)
    • risk factors: hypertension, antiplatelets/anticoagulants, the extent of lateral artery displacement
  • compression syndrome may affect the brainstem and/or cranial nerves


  • atherosclerosis (atherosclerotic dolichoectasia)
    • affects both intra- and extracranial arteries
    • usually occurs in individuals aged > 40 years
    • the combined effect of increased age, chronic hypertension with arterial wall remodeling, and chronic inflammation that may weaken the arterial wall; typical vascular risk factors are present
  • congenital disorders  (non-atherosclerotic dolichoectasia)
  • can develop as a complication of arterial dissection

Clinical presentation

  • ischemic stroke/TIA (30% risk over 5 years)
  • intracranial bleeding, subarachnoid hemorrhage
  • compressive phenomena
    • brainstem compression (associated with basilar dolichoectasia)
    • hydrocephalus
    • neurovascular compression syndrome (NVCS)
      • compression of the optic nerve near the optic chiasma (ICA)
      • impairment of one or more cranial nerves is associated with a tortuous and elongated BA (CN VII, VIII, VI)
  • factors influencing clinical outcome:
    • severity of arterial dilation and the extent of lateral shift
    • signs and symptoms at the time of diagnosis
    • presence of intraluminal mural thrombus
    • progression of ectasia on follow-up imaging

Diagnostic evaluation


  • enlargement and tortuosity of the artery with lateral displacement (shift)
    • basilar arterial diameter > 4.5 mm
  • sometimes, intraluminal thrombi are seen
  • distinguish ectasia from fusiform aneurysm Fusiform aneurysm on basilar artery (CTA)


  • decreased flow velocity
Dolichoectasia of the basilar artery on MRA
Basilar artery dolichoectasia (CTA)

Dolichoectasia of the basilar artery on CTA


  • due to the potential for significant morbidity, a multidisciplinary approach involving neurologists, vascular surgeons, and radiologists is often recommended for comprehensive management and prognostic assessment
  • there is no universally accepted treatment with proven benefit
  • serial imaging to monitor disease progression is suggested
  • patients with previous stroke/TIA may receive antiplatelet therapy or anticoagulation  (AHA/ASA 2021 2a/L-CD)
  • in primary prevention, the benefit of antiplatelet/anticoagulant therapy is uncertain
  • intervention/surgery is reserved for symptomatic cases; the benefit is uncertain (better results in the anterior circulation)
    • bypass
    • resection with anastomosis
    • transposition
    • endovascular flow diverter/stent placement with or without additional coiling
  • lifestyle modifications + management of vascular risk factors, especially hypertension
  • intravenous thrombolysis or mechanical thrombectomy are not contraindicated in acute stroke


  • variable nature of the disease with asymptomatic to malignant course
  • progression more common in younger patients with anterior circulation ectasia
  • relatively high risk of stroke recurrence (up to 60% over 11 years)

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