Vertebrobasilar Disease Research Articles

Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis.

Surgery to the vertebrobasilar region is difficult and not considered in most centres. Furthermore, the basilar artery, with its penetrating branches supplying the brain stem, is likely to be extremely hazardous to dilate. The objective of this review was to assess the effect of vertebral artery percutaneous transluminal angioplasty combined with medical care, compared to medical care alone, in people with vertebrobasilar artery disease. We searched the Cochrane Stroke Groups trials register (to August 1997). We contacted researchers in the field and balloon catheter manufacturers. Randomised trials of vertebral percutaneous transluminal angioplasty (with or without stenting) combined with best medical therapy, compared with best medical therapy alone, in people with symptomatic vertebral artery stenosis. Two reviewers independently applied the inclusion criteria. No completed trials were found. One trial is underway, although few patients with vertebrobasilar disease have been recruited. There is no evidence as yet to assess the effects of percutaneous transluminal angioplasty for vertebral artery stenosis.

Basilar and distal vertebral artery occlusive disease: Correlation of MR imaging and MR angiography : Seynaeve P, Hasso AN, Thompson JR, Hinshaw DB, Jr. (Department of Radiology, Middelheim Hospital, Lindendreef, 1, B-2020 Antwerp, Belgium). J Belge Radiol 1996;79:61–67

The purpose of this study is to evaluate the correlation of brain lesions seen on magnetic resonance imaging with vascular occlusive disease of the basilar and distal vertebral arteries as documented on MR angiography. The clinical findings are also correlated with the findings on MR imaging and MR angiography. The clinical records of twenty-one patients with proven occlusive disease of the distal vertebral and/or basilar arteries were retrospectively reviewed. All the patients were imaged utilizing either the Siemens Magnetom 1.5 T SP 4000 and the Siemens 1.0 T Impact systems. Dual MR angiographic techniques were employed including two-dimensional (2D) and three-dimensional time-of-flight. The 2D sequences utilized fast low angle shot gradient echo sequences. The 3D sequences utilized fast image steady-state precession gradient echo sequences. Gadolinium contrast was utilized for increased angiographic detail in one patient. Magnetization transfer contrast was used in three patients. The individual partitions as well as the maximum intensity pixel projection images were evaluated in each case. The most extensive brain lesions were seen in the group of patients with severe basilar and/or combined vertebrobasilar disease. One-half of these patients showed non-specific scattered foci of T2 lengthening similar to the findings found in a group of patients with noncritical stenosis. MR imaging invariably demonstrated more lesions than were clinically suspected. Even though the brain lesions tended to be more extensive in patients with severe vascular disease, the amount of brain tissue damage was not an adequate parameter to document the degree of vascular narrowing. The degree of vascular narrowing was useful in therapy planning. Such data was obtained by the MR angiograms, but not by MR imaging. MR angiography is a useful complementary examination when lesions in the basilar and distal vertebral vascular territories are diagnosed on MR imaging. MR angiography can differentiate critical from noncritical stenosis and can thus play a key role in the therapeutic decision making process.

Anterior Spinal Artery Collateral Flow in Vertebrobasilar Occlusive Disease

A 49-year-old man was referred for an episode of regressive hemiparesis, caused by proven brainstem infarction. Five weeks later, he started a series of posterior circulation transient ischemic attack

Transient Ischemic Attacks (TIA): Current Issues in Diagnosis and Management

Transient ischemic attacks (TIAs) affect more than 500,000 Americans each year. Stroke risk approximates 4% to 8% within 1 month and increases to 12% to 13% at one year. This has led to stroke being one of the leading causes of death and disability. TIAs are focal neurologic events that are temporary in nature and warn of potential stroke. Most TIAs resolve within 24 hours. Hypertension, smoking, heart disease, and diabetes are the major risk factors for stroke. A comprehensive history of symptoms can help identify carotid vs. vertebrobasilar disease. Timely evaluation of TIAs should be performed according to recent guidelines set forth by the American Heart Association. Aspirin continues to be the gold standard for stroke prevention, conferring a 48% risk reduction in stroke or death. The use of ticlopidine has been recommended as a second-line agent in patients with aspirin intolerance. Surgical intervention (carotid endarterectomy) is indicated in symptomatic patients with high grade stenosis of 70% or greater. For patients with less significant stenosis, inconclusive data exists regarding the benefit of medical vs. surgical treatment. Patient education should address identification of symptoms, the need for prompt medical attention, and risk factor modification. A collaborative plan between clinician and client will facilitate early intervention ultimately leading to preservation of function and prevention of the catastrophic sequelae of stroke.

Vertebrobasilar insufficiency: correlation of clinical and radiologic findings.

Radiological and clinical findings of 20 cases with angiographically proven stenosis or occlusion of the vertebrobasilar system and with clinical signs and symptoms attributable to posterior circulation disorder were studied. A simplified classification of vertebrobasilar arterial disease was presented; type I refers to stenosis of the vertebrobasilar system or subclavian artery, type II refers to vertebrobasilar occlusion, and type III refers to vertebrobasilar branch disease. Type I lesions were further subdivided into types Ia and Ib; type Ia cases showed no infarction in the posterior territory, whereas type Ib cases showed one or more infarctions on computed tomography or magnetic resonance imaging. This angiographic classification is based on treatment options that can be adopted to specific types of lesion. In type I cases, lesions are usually amenable to surgical or angiographic intervention. In type II cases, short-term anticoagulation is the treatment of choice. In type III cases, treatment is primarily aimed at prevention of complication and further stroke.

Magnetic resonance angiography in vertebrobasilar ischemia.

Magnetic resonance angiography is a new, noninvasive technique whose diagnostic value in vertebrobasilar artery disease has not yet been determined. Forty-one patients with acute cerebellar and/or brain-stem ischemia were examined by routine magnetic resonance imaging, extracranial and transcranial Doppler ultrasound, and selective intra-arterial arteriography. Results were correlated with magnetic resonance angiography. Magnetic resonance angiography was accomplished using a three-dimensional time-of-flight gradient-echo technique. Magnetic resonance angiography correctly identified all occlusions, stenoses, and an aneurysm within the distal vertebrobasilar system as revealed by conventional intra-arterial arteriography but missed the diagnosis of vertebral artery dissection in one case. This results in a sensitivity of magnetic resonance angiography of 97% and a specificity of 98.9%. However, the degree of stenoses was difficult to evaluate by magnetic resonance angiography. At least for severe obstructive lesions, this drawback can be eliminated by application of presaturation pulses, which allow the analysis of flow direction and collateral blood flow. Doppler ultrasound studies add useful hemodynamic information for less severe degrees of stenoses. The combined use of magnetic resonance angiography and Doppler ultrasound findings may replace the invasive intra-arterial arteriography examination in many patients with suspected macroangiopathy of the vertebrobasilar arteries.

Sudden bilateral hearing impairment in vertebrobasilar occlusive disease.

Bilateral hearing impairment is rare in vertebrobasilar occlusive disease. Between 1986 and 1991, we encountered seven patients (four men, three women; median age, 61 years; range, 46-71 years) who had sudden bilateral hearing impairment among 503 patients with vertebrobasilar occlusive disease. The main initial neurological symptoms were sudden bilateral hearing impairment, tinnitus, and vertigo. Acute labyrinthitis or Ménière's disease was the initial diagnosis until subsequent brain stem or cerebellar signs appeared. Brain stem auditory evoked potentials were abnormal bilaterally in six patients but had unilateral attenuation of the IV-V complex in the remaining one patient. Computed tomographic scans in all six patients showed multiple hypodense lesions in the brain stem and the cerebellum. Cerebral angiography showed complete occlusion on both vertebral arteries in one patient, occlusion on the left with small caliber on the right in another, and severe stenosis on both sides in a third. There was no opacification of internal auditory arteries in these three patients. The remaining patient had arteriosclerotic changes with faint opacification of the bilateral internal auditory arteries. Five patients had a poor prognosis, with locked-in state in four and severe truncal ataxia in one. We conclude that sudden bilateral hearing impairment in vertebrobasilar occlusive disease is more common than previously recognized and that it may indicate a grave prognosis.

椎骨・脳底動脈閉塞性病変に対する外科的治療

椎骨・脳底動脈閉塞性病変に対する外科的治療

Vertebrobasilar Occlusive Disease: Review of Selected Aspects

Knowledge of the vascular anatomy and supply zones of the thalamus helps interpret the findings in patients with thalamic infarcts. Occlusion of various thalamic arteries arising from the basilar apex, posterior cerebral arteries, and posterior communicating arteries gives rise to prototypic clinical findings and imaging abnormalities. Risk factor analysis, ultrasound, newer cardiac tests and magnetic resonance angiography now make it possible in the majority of patients, to define the most likely etiology of the thalamic infarcts noninvasively. Treatment depends on the nature, location and severity of the vascular lesion, and extent of brain infarction.

Vertebrobasilar Occlusive Disease: Review of Selected Aspects

Knowledge of the vascular anatomy and supply zones of the thalamus helps interpret the findings in patients with thalamic infarcts. Occlusion of various thalamic arteries arising from the basilar apex, posterior cerebral arteries, and posterior communicating arteries gives rise to prototypic clinical findings and imaging abnormalities. Risk factor analysis, ultrasound, newer cardiac tests and magnetic resonance angiography now make it possible in the majority of patients, to define the most likely etiology of the thalamic infarcts noninvasively. Treatment depends on the nature, location and severity of the vascular lesion, and extent of brain infarction.

Vertebrobasilar Arterial Disease

This work attracted me, a primary care geriatrician, because vertebrobasilar insufficiency is often part of the differential diagnosis of common but perplexing problems in my older patients, including unsteady gait, dizziness, vertigo, and falling. Since the vertebrobasilar system accounts for 20% to 30% of intracranial blood flow, more in patients with carotid disease, and supplies 10 of the 12 cranial nerves, all the ascending and descending tracts, the cerebellum, and parts of the cerebral hemispheres, disease within this system can present with myriad signs and symptoms. Given this complexity, the questions I wanted this text to answer were: when should atherosclerotic vertebrobasilar disease be suspected clinically? how can the diagnosis be confirmed in a cost-effective manner? and, which patients should be referred for revascularization to prevent a devastating stroke? This book contains state-of-the-art reports on the pathogenesis, diagnosis, and management of vertebrobasilar ischemia presented in October 1990 at the Second

Cerebral blood flow and metabolism following superficial temporal artery to superior cerebellar artery bypass for vertebrobasilar occlusive disease.

In order to clarify the effectiveness of extracranial-intracranial bypass operations in patients with vertebrobasilar occlusive disease, the authors used positron emission tomography to investigate the cerebral blood flow (CBF) and metabolism of eight patients undergoing superficial temporal artery (STA)-superior cerebellar artery (SCA) bypass procedures. In the preoperative studies, CBF in the region of the posterior fossa was low and the oxygen extraction fraction (OEF) was high, the so-called "misery perfusion syndrome." Such changes were evident in both the posterior circulation and the anterior circulation regions. Postoperatively, there was a significant increase in CBF, a significant decrease in the OEF not only in the region of posterior circulation but also over the entire brain, and a disappearance of the uncoupling between CBF and oxygen metabolism. The STA-SCA bypass procedure is effective in improving CBF and metabolism in patients with vertebrobasilar occlusive disease.

Asymptomatic coronary artery disease in patients with stroke. Prevalence, prognosis, diagnosis, and treatment.

The frequency of angiographically defined asymptomatic CAD in patients with carotid disease is 40%. Although the prognosis of patients with asymptomatic 1-vessel or 2-vessel CAD is good (annual cardiac mortality rate less than 2%), the prognosis of asymptomatic 3-vessel disease or left main CAD is substantially less favorable (annual cardiac mortality 5-8%). Preliminary data from nonrandomized studies suggest that coronary artery bypass surgery significantly lowers cardiac mortality in patients with asymptomatic 3-vessel or left main CAD. Further studies are needed to determine 1) vascular risk factor profiles that are predictive of asymptomatic CAD in patients with cerebrovascular disease and 2) the prevalence of asymptomatic CAD, especially 3-vessel and left main CAD, in patients with a variety of subtypes of cerebrovascular disease (e.g., carotid disease, atherosclerotic vertebrobasilar disease, cardioembolism, penetrating artery disease, stroke of undetermined cause). If the prevalence of asymptomatic 3-vessel or left main CAD is high in a subset of patients with cerebrovascular disease, a randomized study comparing coronary artery bypass surgery with best medical therapy (anti-ischemic agents, lipid-lowering therapy, and aspirin) may be warranted.

Vertebrobasilar Occlusive Disease: Review of Selected Aspects

Vertebrobasilar Occlusive Disease: Review of Selected Aspects

Vertebrobasilar Occlusive Disease: Review of Selected Aspects

Extracranial vertebral artery (VA) dissections usually present with unilateral occipital-nuchal pain or headache, often followed by lateral medullary or cerebellum ischemia. Posterior cerebral artery (PCA) ischemia may also occur. Women predominate, and the dissections are most often bilateral. The distal extracranial and proximal VA segments are most often affected. Recovery is common, and the lesions usually regress. Intracranial VA dissections are found more often in men. The dissections are usually unilateral and often extend into the basilar artery (BA). Subarachnoid hemorrhage (SAH) and brainstem ischemia are the commonest presentations. Ischemia is often severe, and fatal infarctions are common. Occasionally, patients present with mass effect. Some patients have chronic bilateral VA dissections that cause repeated ischemia or recurrent SAH. BA dissections are rarer but also show a male preponderance. Severe, often fatal, ischemia is the commonest presentation. SAH is rarer. The dissections often extend into the distal BA and cause rostral BA, superior cerebellar artery and PCA territory infarction.

Clinical Significance of Retrograde Flow in the Vertebral Artery

Although retrograde vertebral artery flow was described over 100 years ago, its relationship to symptoms remains unclear. We documented 43 patients who were found by duplex scanning to have reverse flow in the vertebral artery. Of this group, seven patients (16%) were found to have symptoms described as typical for the "subclavian steal" syndrome. Nearly one-third were asymptomatic. Of the remaining patients, 13 (30%) presented with nonhemispheric symptoms while nine (21%) had hemispheric symptoms. Nine patients had "to and fro" flow in the vertebral artery. This variant was not found in subclavian steal patients but correlated with nonhemispheric symptoms. During follow-up (mean: 19 months) none of the asymptomatic patients became symptomatic, and there were no strokes or stroke-related deaths. Surgical procedures which restored antegrade vertebral artery flow did not necessarily improve symptoms of posterior circulation ischemia. In some patients improvement in posterior circulation symptoms was noted following carotid endarterectomy. It is concluded that retrograde flow in the vertebral artery is, per se, a benign entity. Accurate selection of surgical candidates remains imprecise. It will require not only identification of vertebrobasilar disease but as yet undefined tests to assure symptoms are due to these stenoses.

Extracranial surgery for vertebro-basilar ischaemia (Experience of 8 cases)

Atheromatous lesions of the proximal vertebral artery and the subclavian artery may lead to ischaemic manifestations, occasionally with severe consequences in the vertebro-basilar territory. These transient ischaemic attacks are most often caused by haemodynamic insufficiency rather than thrombo-embolic complications addressed by anticoagulant and antiaggregant treatments. In this study, 8 cases of vertebro-basilar ischaemia (VBI), secondary to subclavian and proximal vertebral artery lesions, are reported. Surgical techniques, subclavian-to-subclavian artery by-pass (5 cases) and vertebral to common carotid artery transposition (3 cases) are described with their respective results. Through a review of the literature, the various operative modalities are discussed in the different pathological conditions of the proximal extracranial vertebro-basilar disease. It appears that the subclavian to subclavian artery by-pass as well as the vertebral-to-common carotid artery transposition are safe surgical procedures with strikingly low morbidity and mortality rates. The widely achieved relief of the ischaemic episodes, undoubtedly makes this surgery an alternative to medical treatment.

Color-coded Doppler sonography of vertebral arteries.

Color-coded Doppler sonography of the vertebral arteries was performed in 86 patients who had a history of vertebrobasilar disease. The origin of the artery was visualized in 87.2% on the right and 70.9% on the left side. The inter-transverse portion of the vertebral artery was visualized in 95% on the right and 97% on the left side. The atlas loop could be visualized in 88.4% on the right and 84.9% on the left side. Pathologic findings were hypoplasia (n = 4), stenosis (n = 19), dissection (n = 2), occlusion (n = 7), kinking (n = 12), cervical tumors (n = 3), and subclavian steal syndrome (n = 3). Nine postoperative patients had subclavian and vertebral artery reimplantation to the common carotid artery. The characteristic color-coded Doppler sonographic features of these findings are presented and discussed.

Bilateral loss of vision in bright light.

We describe four patients with episodic bilateral vision impairment related exclusively to light exposure. Each had angiographically documented bilateral high-grade stenosis or occlusion of the internal carotid arteries. This phenomenon appears to be related to bilateral simultaneous retinal ischemia delaying regeneration of visual pigments in the pigment epithelial layer. It must be distinguished from bilateral occipital lobe ischemia caused by vertebrobasilar system disease.

Clinical Analysis of STA-SCA Bypass for Vertebrobasilar Occlusive Disease.

In order to clarify the effectiveness of extracranial- intracranial bypass in cases of vertebro-basilar occlusive disease, we investigated the operative complication, clinical course and follow-up study of 30 cases undergoing superficial temporal artery-superior cerebellar artery (STA-SCA) bypass surgery. Postoperative angiogram showed the patency of the anastomoses in all cases. No serious surgical complications were observed. The outcome on discharge was excellent, with no morbidity and one mortality which was due to cardiac infarction. In the follow-up study, there were four cases with ischemic symptoms, two with transient ischemic attack and two with completed stroke, one of which was a supratentorial infarction due to internal carotid artery occlusion and the other was a small infarction of pons. There were also two deaths due to cardiac infarction and diabetes mellitus. Favorable outcomes were obtained for the remaining cases. The present study suggests that, STA-SCA bypass, can be performed without surgical and systemic complications and used as an effective therapy for vertebrobasilar ischemia.