eMedicine Specialties > Neurology > Neuro-vascular Diseases

Basilar Artery Thrombosis: Differential Diagnoses & Workup

Author: Salvador Cruz-Flores, MD, MPH, Professor of Neurology, Director of Souers Stroke Institute, Department of Neurology and Psychiatry, St Louis University School of Medicine; Director, Mid-America Stroke Network and Neuroscience Critical Care Unit, St Louis University Hospital
Coauthor(s): Sombat Muengtaweepongsa, MD, Faculty, Department of Neurology, Thammasat University, Pathumthani, Thailand
Contributor Information and Disclosures

Updated: Aug 18, 2009

Differential Diagnoses

Central Pontine Myelinolysis
Cerebellar Hemorrhage
Intracranial Hemorrhage
Metastatic Disease to the Brain
Subarachnoid Hemorrhage

Other Problems to Be Considered

Basilar meningitis
Basilar migraine
Cerebellar hemorrhage with brainstem compression
Cerebellar infarct with edema and brainstem compression
Pontine hemorrhage
Space-occupying lesions in the posterior fossa
Supratentorial hemispheric mass lesions with mass effect, herniation, and brainstem compression

Workup

Laboratory Studies

  • The laboratory workup should include a complete blood cell count, electrolyte values, BUN and creatinine determination, international normalized ratio (INR), prothrombin time and activated partial thromboplastin time, and lipid profile.
  • Young patients (<45 y) or patients with no evidence of atherosclerosis should be investigated for the presence of procoagulant conditions. However, these tests may need to be repeated several weeks later after the acute event to establish whether the abnormality was a response to the acute event or an actual abnormality. These patients are typically screened for the following procoagulant conditions:
    • Protein C, protein S, and antithrombin III deficiencies, especially if the patients has evidence of paradoxical embolism because these disorders have a stronger association with venous rather than arterial thrombosis
    • Lupus anticoagulant and anticardiolipin antibodies
    • Homocysteine level
  • Creatine kinase levels, cardiac isoenzyme values, and troponin levels should be tested in the following:
    • All symptomatic patients (eg, those with chest pain)
    • Patients with ECG evidence of ischemic changes, because of the high incidence of concomitant coronary artery disease in patients with cerebrovascular disease

Imaging Studies

  • CT scanning of the head
    • CT scanning is usually the first imaging study performed.
    • It has a sensitivity of greater than 95% for identifying hemorrhage within the first 24 hours of onset and helps to exclude intra- or extra-axial hemorrhage.
    • It has a low sensitivity for early ischemia and usually has the disadvantage of significant artifacts caused by the bony structures surrounding the brain stem and cerebellum.
    • Helpful findings include infarcts in the thalamus and/or occipital lobe or lobes, which indicate involvement of the rostral basilar artery; hyperdense basilar artery, which indicates probable occlusion;5 and dilated vertebral and/or basilar artery, which indicates a dolichoectatic vessel.

      Hyperdense basilar artery (arrow).

      Hyperdense basilar artery (arrow).

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      Hyperdense basilar artery (arrow).

      Hyperdense basilar artery (arrow).

    • Spiral CT angiography is helpful in identifying occluded and dolichoectatic vessels.

      Spiral CT angiography showing occluded basilar ar...

      Spiral CT angiography showing occluded basilar artery.

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      Spiral CT angiography showing occluded basilar ar...

      Spiral CT angiography showing occluded basilar artery.

    • The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) with CT Angiography Source Images (CTASI) is a predictive scale of functional outcome in patients with basilar artery thrombosis.
      • Pc-ASPECTS allocates the posterior circulation 10 points. One point each is subtracted for hypoattenuation on CTASI in left or right thalamus, cerebellum, or posterior cerebral artery territory, respectively, and 2 points each are subtracted for hypoattenuation on CTASI in any part of the midbrain or pons. A pc-ASPECTS score of 10 indicates absence of visible posterior circulation ischemia; a score of 0 indicates hypoattenuation in all pc-ASPECTS territories.
      • The CTASI pc-ASPECTS score can identify basilar artery thrombosis patients who will have a poor clinical outcome despite recanalization.6
  • MRI and magnetic resonance angiography (MRA)
    • MRI and MRA are more sensitive than CT scanning for identifying ischemia and vascular occlusion.
    • Gradient echo technique, with its higher sensitivity for identifying blood, and diffusion/perfusion-weighted images, with a higher sensitivity for identifying ischemia and hypoperfusion, make MRI a more powerful tool in the treatment of these patients.

      Diffusion-weighted MRI images showing a right cer...

      Diffusion-weighted MRI images showing a right cerebellar infarct.

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      Diffusion-weighted MRI images showing a right cer...

      Diffusion-weighted MRI images showing a right cerebellar infarct.

    • Helpful findings include lesions that suggest microbleeds, tumors, vertebral/basilar dolichoectasia, and vertebral/basilar dissections.
    • MRA can identify vertebral/basilar occlusion with sensitivity as high as 97% and a specificity of 98%.

      Magnetic resonance angiography demonstrating the ...

      Magnetic resonance angiography demonstrating the absence of flow in the vertebrobasilar system.

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      Magnetic resonance angiography demonstrating the ...

      Magnetic resonance angiography demonstrating the absence of flow in the vertebrobasilar system.

    • MRA has limitations because it frequently overestimates the degree of stenosis. Severe stenosis may resemble vascular occlusion. This occurs because the image of the vessel with MRA is a flow-related phenomenon; therefore, severe stenosis with significant flow compromise may result in poor visualization of the vessel.
    • Baseline brainstem diffusion-weighted imaging (DWI) lesion score can be used as an independent predictor for clinical outcome in patients with basilar artery thrombosis.7
      • The total number of brainstem arterial territories with abnormal DWI defines the brainstem DWI lesion score, between 0 and 22. A score of 0 indicates absence of visible posterior circulation ischemia; a score of 22 indicates DWI restriction in the entire brainstem.7
      • In a study published in 2009, a score was used to evaluate the extent of the brainstem DWI lesion on pretreatment MR imaging according to the arterial territories of the medulla, pons, and midbrain. The number of arterial territories with abnormal DWI was assessed at each brainstem level, including anteromedial, anterolateral, lateral, and posterior territories: 0-8 in the medulla, 0-6 in the pons, and 0-8 in the midbrain.7
  • Transcranial Doppler
    • Transcranial Doppler (TCD) is a useful tool for evaluating cerebrovascular disease; however, it is often inaccurate.
    • In patients with basilar artery disease, the reported sensitivity is 72% and the specificity is 94%.
    • TCD is helpful for purposes of follow-up once an initial evaluation has demonstrated the lesion.
    • The flow direction detected by TCD, in combination with CT angiography, might be useful before performing invasive angiography for helping predict the area of stenosis or occlusion.8

Other Tests

  • Electrocardiography
    • ECG should be performed in all patients during the initial evaluation because it can reveal paroxysmal arrhythmias such as atrial fibrillation. Additionally, the prevalence of coronary disease is high in patients with cerebrovascular disease.
    • Ischemic changes seen with ECG should be investigated further with serum creatine kinase measurements, cardiac isoenzyme profiles, and/or troponin levels for the following reasons:
      • Of patients with acute stroke, 5-20% have an arrhythmia.
      • Additionally, 2-3% have a myocardial infarction.
      • The presence of arrhythmias (eg, atrial fibrillation) has an impact on the long-term management plan for stroke prevention.
  • Echocardiography:
    • This should be considered in all patients because cardioembolism is frequent enough in this population.
    • Moreover, even those patients with documented atherothrombosis may have a concomitant cardiac source of embolism.

Procedures

  • Catheter angiography
    • With the availability of noninvasive imaging modalities such as MRI, MRA, and TCD, the role of angiography has changed; however, it still is considered the criterion standard. Angiography is performed (1) when MRA cannot be performed because the patient has an absolute contraindication such as a pacemaker or (2) when the quality of noninvasive studies is not satisfactory or the results of other tests do not explain clinical findings.

      Right vertebral artery angiography showing an occ...

      Right vertebral artery angiography showing an occlusion with no flow in the basilar artery.

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      Right vertebral artery angiography showing an occ...

      Right vertebral artery angiography showing an occlusion with no flow in the basilar artery.



      Angiography performed after intra-arterial thromb...

      Angiography performed after intra-arterial thrombolysis and angioplasty showing recanalization and perfusion of the basilar artery and its branches.

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      Angiography performed after intra-arterial thromb...

      Angiography performed after intra-arterial thrombolysis and angioplasty showing recanalization and perfusion of the basilar artery and its branches.

    • Angiography should be pursued as a first-line diagnostic test after CT scanning and once the decision is made that recanalization should be performed.
  • The primary goals of the workup are to (1) establish the type of vascular lesion and the mechanism of the stroke and, if early enough, (2) establish if acute intervention is needed to achieve recanalization.

More on Basilar Artery Thrombosis

Overview: Basilar Artery Thrombosis
Differential Diagnoses & Workup: Basilar Artery Thrombosis
Treatment & Medication: Basilar Artery Thrombosis
Follow-up: Basilar Artery Thrombosis
Multimedia: Basilar Artery Thrombosis
References
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Further Reading

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Keywords

basilar artery occlusion, anterior inferior cerebellar artery, AICA, posterior cerebral artery, PCA, atherothrombosis, embolism, arterial dissection, atherosclerotic occlusion, vertebrobasilar insufficiency, VBI, stroke, hypertension, partial basilar artery occlusion, intravenous thrombolysis, atherosclerotic basilar artery stenosis, occlusion of the distal basilar artery, pontine ischemia, locked-in syndrome, top-of-the-basilar syndrome, stroke, neck injury, chiropractic manipulation, atrial fibrillation.

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Contributor Information and Disclosures

Author

Salvador Cruz-Flores, MD, MPH, Professor of Neurology, Director of Souers Stroke Institute, Department of Neurology and Psychiatry, St Louis University School of Medicine; Director, Mid-America Stroke Network and Neuroscience Critical Care Unit, St Louis University Hospital
Salvador Cruz-Flores, MD, MPH is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Neurology, American College of Physicians, American Heart Association, American Medical Association, American Society of Neuroimaging, American Stroke Association, National Stroke Association, Neurocritical Care Society, and Society of Critical Care Medicine
Disclosure: NovoNordisk Grant/research funds clinical trial; Photothera INC Grant/research funds clinical trial; IMRX therapeutics Inc Grant/research funds clinical trial; Coaxia Inc Grant/research funds clinical trial; Neurobiological Technologies Inc Grant/research funds clinical trial

Coauthor(s)

Sombat Muengtaweepongsa, MD, Faculty, Department of Neurology, Thammasat University, Pathumthani, Thailand
Disclosure: Nothing to disclose.

Medical Editor

Draga Jichici, BSc, MD, FRCP, Associate Clinical Professor, Department of Medicine, Division of Neurology and Critical Care Medicine, McMaster University, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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