Vertebral-basilar Insufficiency Research Articles

Unraveling the complexity: A comprehensive guide to subclavian steal syndrome.

Subclavian steal syndrome is a diagnosis that is thought to be relatively uncommon even though its occurrence is not well understood. Some individuals may experience crippling symptoms of arm ischemia and vertebral-basilar insufficiency due to subclavian steal, which is more frequent than the accompanying illness. Patients with uneven arm blood pressure or unilaterally faint pulses should be evaluated for subclavian steal. Although it is not always necessary to check the blood pressure and pulse on both sides, they become significant when these measurements differ and are accompanied by vertebral-basilar or arm ischemia symptoms. Although subclavian steal does not significantly increase the risk of stroke, it is nevertheless essential to recognize and treat asymmetric blood pressure and weak pulses as these may be signs of subclavian steal syndrome. This page thoroughly analyses the aetiology of subclavian steal syndrome, signs, symptoms, diagnosis, and available treatments.

MORPHOLOGICAL ASPECTS OF STATIC-LOCOMOTOR FUNCTION DISORDERS IN CHRONIC CEREBRAL ISCHEMIA

In our studies, the predominance of the proportion of chronic vertebral-basilar insufficiency in women was found. Men were significantly more likely to have acute brain disorder in the vertebral-basilar sistem. In persons younger than 50 years, no ischemic strokes were detected in 87% of cases, this indicator decreased by half at the age of 50 to 60 years and remained in persons older than 60 years. Thus, the most vulnerable age period in relation to the development of stroke is the age over 52.6 years. According to WHO statistics, more than 15 million cases of stroke are registered annually in the world, of which more than 30% die within a year, more than 80% become disabled.

Vestibular vertigo

Vestibular vertigo is most often caused by benign paroxysmal positional vertigo (BPPV), Meniere's disease, vestibular neuritis, vestibular migraine or stroke. Features, diagnosis and treatment of vestibular vertigo in patients with these diseases are discussed. The authors analyze common diagnostic errors based on the data of 700 outpatients (205 men and 495 women, aged 25-88 years, mean age 55 years). It is noted that the cause of vertigo is often misdiagnosed with vertebral-basilar insufficiency, discirculatory encephalopathy, cervical spine pathology; at the same time, BPPV, Meniere's disease, vestibular neuritis or vestibular migraine is diagnosed less often. This fact reflects the lack of awareness of physicians about these diseases. BPPV, Meniere's disease and migraine are effectively treated and therefore their diagnosis and adequate treatment are of great importance.

Utility of transcranial Doppler(TCD) in the treatment and diagnosis Of Vertebral Basilar Insufficiency(VBI) (P5.215)

Utility of transcranial Doppler(TCD) in the treatment and diagnosis Of Vertebral Basilar Insufficiency(VBI) (P5.215)

Acute vestibular disorder in the elderly: stroke or peripheral vestibulopathy

Acute vestibular disorder is a frequent cause of urgent hospitalization in elderly patients. A CNS vascular disorder is often thought to be a cause of vertigo and a patient is diagnosed with stroke or transitory ischemic attack (TIA) or vertebral-basilar insufficiency. Despite the higher risk of cerebrovascular disease in the elderly, stroke and TIA are not the only cause of acute vestibular disorder. Hyperdiagnosis of cerebrovascular diseases in patients with acute vertigo often leads to underdiagnosis of peripheral vestibular disorders that could be successfully treated if timely diagnosed. The differential diagnosis of the lesions of central and peripheral vestibular systems is based on clinical examination of patients with acute vertigo including an analysis of cerebrovascular risk factors, characteristics of vertigo, nystagmus and careful identification of focal neurological symptoms.

Современный зарубежный опыт изучения вертебробазилярной недостаточности: клинические проявления и проблемы диагностики.

Современный зарубежный опыт изучения вертебробазилярной недостаточности: клинические проявления и проблемы диагностики.

Hybrid surgical treatment of patients with vertebral-basilar insufficiency

Hybrid surgical treatment of patients with vertebral-basilar insufficiency

Extracranial–Intracranial Cerebral Revascularization: Indications and Results

Objective To present a case-series study of extracranial–intracranial (EC–IC) bypass procedures performed in our service and evaluate indications and results. Method The medical records of 30 patients undergoing 32 EC–IC anastomosis procedures were evaluated. Seventeen patients were male (56.6%). The age ranged from 26 to 85 years (mean: 58.2). The follow-up ranged from 1 to 211 months (mean: 54). We evaluated the indications and complications of the surgical procedures. Results The bypass procedures comprised 28 STA–MCA anastomosis (87,5%) and four posterior circulation anastomosis. The main indications included cervical internal carotid artery occlusion (19 cases), Moyamoya disease (3 cases), giant aneurysms (3 cases), intracranial arterial stenosis (2 cases), and vertebral–basilar insufficiency (3 cases). On follow-up, graft patency was 93.7%, confirmed in half of the cases by arterial digital subtraction angiography, magnetic resonance angiography, and CT angiography. There was no surgical mortality. Three patients had PO complications (9.3%), including one case of ischemia (3.1%). Conclusion The EC–IC bypass is a procedure with low morbidity and mortality. The indication of EC–IC bypass surgery for cerebral atherosclerotic disease should not be generalized. The EC–IC bypass can be indicated for cerebral revascularization in Moyamoya disease, intracranial stenosis, and in the management of complex aneurysms. This procedure can be an alternative in the treatment of vertebral–basilar insufficiency.

Iatrogenic Subclavian Steal Syndrome.

New complications are resulting from percutaneous transluminal angioplasty (PTA) and stent deployment. A 43-year-old female, admitted with weakness in the right arm, was diagnosed with right subclavian stenosis. Following PTA and a Palmaz stent deployment, her condition worsened, and symptoms spread. A corrective surgical procedure found the Palmaz stent to be almost completely compressed. The stent and plaques were carefully extracted. The etiology of compressed stent was probably due to an insufficient radial force or Hoop strength of stent. If an occlusion of the subclavian artery occurs at the segment proximal to the orifices of vertebral artery and internal mammary artery, a vertebral-subclavian steal syndrome may occur. This can be diagnosed in patients manifesting symptoms that include vertebral-basilar arterial insufficiency and a difference in brachial systolic blood pressure of at least 30 mm Hg between the two arms, with a bruit at the base of the neck or in the supraclavicular area. </hea

Bow Hunter's Syndrome Masquerading as Definite Ménière's Disease

Bow Hunter's syndrome (BHS) results from vertebral-basilar insufficiency secondary to mechanical stenosis or occlusion of the unilateral vertebral artery at the atlanto-axis during head rotation. It is sometimes difficult to detect BHS, which is often ignored at other processes. A 44-year-old woman had up to 13 episodes of acute vertigo with left tinnitus, which was related to head rotation. Pure tone audiometry documented left side hearing impairment, so definite Ménière's disease was impressed; however, electronys-tagmography, a caloric test, posturagraphy, a cervical vestibular evoked myogenic potential, color-coded duplex sonography and magnetic resonance imaging/angiography disproved this. Ménière's disease was impressed and was attributed to BHS, which was related to a vertebral-basilar artery anomaly. The patient was treated conservatively and changed her work-style, and the symptoms did not recur over the following half year. Therefore, BHS can masquerade as Ménière's disease. We report this condition because of its rarity.

Dizzy Spells Complicating Hypertension Management

Dizzy Spells Complicating Hypertension Management

Subclavian steal syndrome

Subclavian steal syndrome is a systemic entity that is well-documented in the medical literature. It occurs when the subclavian artery becomes stenosed or occluded and blood flow is reversed in the ipsilateral vertebral artery. This siphoning or "stealing" of blood has traditionally been thought to cause symptoms of vertebral-basilar insufficiency. Recent literature indicates that subclavian steal syndrome is often asymptomatic, but may be associated with a wide variety of signs and symptoms of vertebro-basilar, carotid, or upper extremity ischemia, and that the manifestation of the condition is probably dependent on the patency of the other cranial arteries. This report describes three patients who underwent comprehensive eye examinations and who had been previously diagnosed with subclavian steal phenomenon. The initial symptoms included: unilateral Hollenhorst plaque, unilateral fibrino-platelet plaque, and one patient with no symptoms These patients were followed for their ocular conditions concurrently with their physicians following their systemic circulatory disease. Signs and symptoms, imaging and laboratory tests, and management are discussed. Subclavian steal syndrome is a systemic condition that may manifest ocular signs and symptoms that optometrists should recognize, and which merits referral for systemic evaluation and treatment as necessary Patients who manifest signs and symptoms of vertebro-basilar insufficiency, carotid territory ischemia, or ocular symptoms of atherosclerosis may be diagnosed with subclavian steal syndrome as evaluation of the extracranial arteries is pursued.

Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.

めまい診断の画像の役割

Diagnostic imaging for vertigo and dizziness has remarkedly advanced and has been used to diagnose the central origin.We investigated here, the quality of diagnostic imaging for vertigo and dizziness to improve the diagnostic accuracy using 67 patients.The examinations included brain CT, MRI, MRA, target CT, SPECT, vestibular function test and audiological tests.Of a total of 67 cases, the following conditions were identified: Menier's disease; 15 cases, vertebral basilar insufficiency (VBI); 16, benign paroxysmal positional vertigo (BPPV); 3, vestibular neuritis; 10, acoustic tumor (AT); 6, lateral medullary syndrome; 1, cerebellar infarction; 1, cerebellar degeneration; 1, and pontile glioma; 1, and others; 13.We found different advantages of diagnostic imaging compared to the vestibular function tests. For example, in 20% of cases of Menier' s disease, the distance between the posterior semicircular canal and the posterior proteus surface (P-P distance) on CT was significantly shorter in the affected side than that in the normal side. In 43% of VBI cases, multiple lacuna infarctions were found using MRI.It is important to choose the appropriate imaging technique to directly diagnose or differentiate between various diseases. We discused here, the importance and the merits of imaging for the diagnosis of vertigo and dizziness.

Basilar artery dolichoectasia. Review of the literature and six patients studied with magnetic resonance angiography.

Six patients for whom computed tomography revealed a curvilinear calcific mass anterior to their brainstem were evaluated and magnetic resonance imaging and magnetic resonance angiography were performed on each. Magnetic resonance studies confirmed the suspicion of basilar artery dolichoectasia, and demonstrated a partial thrombus in the basilar artery in 1 patient. The patients' clinical features were combined with those of basilar artery dolichoectasia patients reported in the literature (n = 122) who had case histories sufficiently detailed enough to determine each person's mode of clinical presentation. Basilar artery dolichoectasia patients were more often men (95/128, 74%) and had a mean age of 59 +/- 11 years. Of the 128 patients studied, there were cranial nerve compressive signs in 74 (58%), especially facial spasm (29/74, 39%) and trigeminal neuralgia (20/74, 27%); vertebral basilar insufficiency or vertebral basilar stroke or both in 61 (48%); hydrocephalus in 40 (31%); compressive brainstem symptoms and signs that progressed clinically in 31 (24%); and arterial hypertension in 31 (24%). Magnetic resonance imaging and magnetic resonance angiography safely diagnose this interesting arterial abnormality. The modes of clinical presentation of this disorder are reviewed.

緊急入院を要しためまい患者の検討

Two hundred ten cases that required emergency hospitalizaiton for vertigo during the last 5 years were reviewed. Among patients with peripheral vertigo, we found Meniere's disease (typical and atypical), sudden deafness, labyrinthitis due to otitis media, and acute inner ear impairment, in that order; and among those with the central type, we often encountered vertebral basilar insufficiency (VBI)/central vascular impairment. Regarding the median age for the respective diseases, labyrinthitis due to otitis media and acute inner ear impairment occurred more frequently among younger patients, while VBI/central vascular impairment was more common among the elderly. Onset tended to be most frequent in the spring. Meniere's disease (typical and atypical), sudden hearing loss and VBI/central vascular impairment required longer hospitalization. Blood sugar, lipids and blood pressure were very frequently abnormal in such cases.

椎骨脳底動脈不全に伴う前下小脳動脈症候群

Two patients complaining of hearing loss with vertigo were examined radiologically and neurotologically. Electronystagmography and positional nystagmus testing showed central disturbances. Vertebral angiography (VAG) showed narrowings in the vertebral artery (VA) concomitant with defects in the anterior inferior cerebellar artery (AICA) diagonally opposite to the respective impaired VA branch. We demonstrate in this study that the AICA syndrome resulted from vertebral basilar insufficiency (VBI).Today, due to improvements in CT, MRI and angiography, the AICA syndrome is much better understood. Since VBI will futher complicate AICA syndromes and other secondary disturbances, we conclude that VAG should be performed with care certain cases of vertigo thought to be caused by VBI.

A directed approach to the dizzy patient

We initiated a prospective study of the dizzy patient to identify key factors on which a directed evaluation could be based. This study used a standardized history, physical examination, and basic laboratory evaluation totalling 66 items to assist collection of relevant clinical information on 125 patients. Diagnosis was based on the emergency physicians' diagnosis. This was modified when necessary based on one month of follow-up using diagnostic criteria adapted from previous studies. The most common disorder was some form of peripheral vestibular disorder, found in 54 patients (43%). These patients were typically vertiginous and were managed successfully as outpatients. Despite correlations with multiple factors, this diagnosis was best predicted by positive Nylen-Barany test with either vertigo, vomiting, or both with 94% specificity and 43% sensitivity. Potentially serious causes were identified, including medication-related, seizure, stroke, transient ischemic attacks, vertebral-basilar insufficiency, hypertension, pericarditis, arrhythmias, and all those requiring hospitalization. The best predictors, either older age, lack of vertigo, or neurologic deficit, could identify 86% of "serious" dizziness with 42% specificity. The following tests were of low yield and may be done in a directed manner based on a brief history: Valsalva, carotid stimulation, Romberg and Quix tests, mental status examination, complete blood count, serum electrolytes, and BUN. Our results do support routine testing of glucose in all patients and monitoring rhythm in patients age 45 and older. Such a directed approach could rapidly classify a significant number of dizzy patients and forego many time- and cost-intensive elements of provocative examination and laboratory testing.

Benefits, shortcomings, and costs of EEG monitoring.

A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.

Current management of vertebral basilar occlusive disease.

The current medical and surgical management of vertebral basilar occlusive disease has been reviewed, with the emphasis on the lack of definitive data proving the absolute efficacy of one form of therapy. In addition, the renewed interest in medical and surgical therapy of the vertebral system has been displayed. More experience and detailed study should be directed towards the final solution of the best treatment for vertebral basilar insufficiency. The extracranial vascular procedure of choice for correcting a vertebral stenosis appears to be a vertebral to common carotid artery anastomosis. This therapy can be used for a subclavian steal syndrome, but the more established surgical therapy for a subclavian steal syndrome is a common carotid to subclavian bypass graft. The innovative microvascular techniques are too few in number of produce a definitive statement. However, the capability of these procedures has been well-demonstrated, and the patency rate is acceptable. On the other hand, these procedures are time consuming and, because they have been selected for patients who have failed in medical therapy, are tainted in that they are used with patients very difficult to manage successfully. With more aggressive diagnostic arteriographic study and renewed neurological interest in the vertebral basilar system, definite treatment regimens can be anticipated. Doubtless, the results of the extracranial-intracranial bypass study will have significant impact on our future approach.