eMedicine Specialties > Neurosurgery > Vascular

Vertebral Artery Atherothrombosis: Workup

Author: Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Coauthor(s): Mark D Morasch, MD, Clinical Practice Director, Division of Vascular Surgery, Assistant Professor of Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine
Contributor Information and Disclosures

Updated: Feb 20, 2007

Workup

Imaging Studies

  • A precise diagnosis of vertebrobasilar ischemia begins with an accurate assessment of the presenting symptom complex. This must be followed by efforts to exclude other causes for the patient's symptoms. A thorough investigation excludes the following:
    • Inner ear pathology, including rare cerebellar-pontine angle tumors
    • Cardiac arrhythmias
    • Internal carotid artery stenosis/occlusion
    • Inappropriate use of prescription medications, particularly antihypertensives
  • An important aspect of the history is identifying triggering events such as positional or postural changes. This is followed by a thorough physical examination, which includes palpation, auscultation, pulse examination, and comparative arm blood pressures (recumbent and standing).
  • Once a suspicion of vertebrobasilar ischemia has been entertained, only a few studies clearly ascertain vertebral anatomy.
  • Duplex ultrasound
    • While duplex ultrasound is an excellent tool for detecting lesions in the carotid artery, it has significant limitations when used to detect vertebral artery pathology.
    • The usefulness of duplex ultrasound lies in its ability to confirm reversal of flow within the vertebral arteries and to detect flow velocity changes consistent with proximal stenosis.
  • MRI
    • Recent developments in MRI allow for accurate and noninvasive visualization of the vertebral and basilar arteries as well as the surrounding posterior fossa structures.
    • Transaxial MRI is also invaluable in detecting acute and chronic posterior fossa infarcts (see Image 1). This has been enhanced by the development of magnetic resonance angiography (MRA) with 3-dimensional reconstructions and maximum image intensity (MIP) imaging (see Image 2).
  • Arteriography
    • Despite technologic advances, arteriography remains the diagnostic test of choice. In fact, most surgeons consider selective subclavian and vertebral artery angiography a mandatory test prior to any operative intervention.
    • The most common site of vertebral artery disease is at its origin.
    • Confirmation of the diagnosis often requires special radiographic maneuvers and projections not typically included in standard aortic arch evaluations. Patients with suspected vertebral artery compression should undergo dynamic angiography, which incorporates provocative positioning.
    • Lastly, delayed imaging should be performed in order to demonstrate reconstitution of the extracranial vertebral arteries through cervical collaterals (see Image 3).

More on Vertebral Artery Atherothrombosis

Overview: Vertebral Artery Atherothrombosis
Workup: Vertebral Artery Atherothrombosis
Treatment: Vertebral Artery Atherothrombosis
Follow-up: Vertebral Artery Atherothrombosis
Multimedia: Vertebral Artery Atherothrombosis
References
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References

  1. Berguer R, Kieffer E. Surgery of the Arteries of the Head. New York: Springer-Verlag. 1992.

  2. Berguer R, Morasch MD, Kline RA. A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease. J Vasc Surg. May 1998;27(5):852-9. [Medline].

  3. Berguer R, Flynn LM, Kline RA, Caplan L. Surgical reconstruction of the extracranial vertebral artery: management and outcome. J Vasc Surg. Jan 2000;31(1 Pt 1):9-18. [Medline].

  4. Caplan L. Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture-2000. Stroke. Aug 2000;31(8):2011-23. [Medline].

  5. Chastain HD, Campbell MS, Iyer S, et al. Extracranial vertebral artery stent placement: in-hospital and follow-up results. J Neurosurg. Oct 1999;91(4):547-52. [Medline].

  6. Cloud GC, Markus HS. Vertebral Artery Stenosis. Curr Treat Options Cardiovasc Med. Apr 2004;6(2):121-127. [Medline].

  7. Hauth EA, Gissler HM, Drescher R, et al. Angioplasty or stenting of extra- and intracranial vertebral artery stenoses. Cardiovasc Intervent Radiol. Jan-Feb 2004;27(1):51-7. [Medline].

  8. Kieffer E, Praquin B, Chiche L, et al. Distal vertebral artery reconstruction: long-term outcome. J Vasc Surg. Sep 2002;36(3):549-54. [Medline].

  9. Lin YH, Juang JM, Jeng JS, et al. Symptomatic ostial vertebral artery stenosis treated with tubular coronary stents: clinical results and restenosis analysis. J Endovasc Ther. Dec 2004;11(6):719-26. [Medline].

  10. Malek AM, Higashida RT, Phatouros CC, et al. Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement. Stroke. Oct 1999;30(10):2073-85. [Medline].

  11. Rancurel G, Kieffer E, Arzimanglou A. Hemodynamic vertebrobasilar ischemia: Differentiation of hemodynamic and thromboembolic mechanisms. In: erguer R, Caplan LR, eds, Vertebrobasilar Arterial Disease. St. Louis: Quality Medical Publishing, Inc;1992:40-51.

  12. Yates PO. Atheromatous lesions of the vertebral arteries and brain infarction. In: Vertebrobasilar Arterial Disease. St. Louis: Quality Medical Publishing, Inc;1992:3-10.

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Further Reading

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Keywords

vertebral artery atherothrombosis, atherosclerosis, atherosclerotic lesions, atherosclerotic plaque, vertebral artery stenosis, hemodynamic symptoms, vertebrobasilar ischemia, fibromuscular dysplasia, FMD, carotid artery disease, vasculopathy, Takayasu disease, osteophyte compression, aneurysms, arteritides, anticoagulation, vertebral artery reconstruction, subclavian-vertebral artery endarterectomy, saphenous vein bypass

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Contributor Information and Disclosures

Author

Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Mark K Eskandari, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, International Society of Endovascular Specialists, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Interventional Radiology, Society of University Surgeons, and Western Surgical Association
Disclosure: Terumo Consulting fee Consulting; W. L. Gore & Associates Consulting fee Consulting; Abbott Vascular Consulting fee Consulting; Cordis Consulting fee Consulting; Boston Scientific Consulting fee Consulting

Coauthor(s)

Mark D Morasch, MD, Clinical Practice Director, Division of Vascular Surgery, Assistant Professor of Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine
Mark D Morasch, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, and Central Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Michael G Nosko, MD, PhD, Chief, Division of Neurosurgery, Director of Neurovascular Surgery, Medical Director of Neuroscience Unit, Associate Professor, Department of Surgery, University of Medicine and Dentistry at New Jersey
Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ryszard M Pluta, MD, PhD, Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Senior Researcher, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, NIH
Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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