eMedicine Specialties > Physical Medicine and Rehabilitation > Stroke

Vertebrobasilar Stroke: Differential Diagnoses & Workup

Author: Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Coauthor(s): Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Contributor Information and Disclosures

Updated: Jul 15, 2009

Differential Diagnoses

Other Problems to Be Considered

Central pontine myelinolysis
Metastatic disease of the brain
Subarachnoid hemorrhage
Basilar meningitis
Basilar migraine
Cerebellopontine angle tumors
Supratentorial hemispheric mass lesions with mass effect, herniation, and brainstem compression

Workup

Laboratory Studies

  • Laboratory workup should include the following:
    • Complete blood count (CBC)
    • Electrolytes
    • Blood urea nitrogen (BUN) and creatinine
    • Prothrombin time and activated partial thromboplastin time (aPTT)
    • Cholesterol level
    • Lipid profile
  • Patients who are younger than 45 years or who have no evidence of atherosclerosis should be investigated for the presence of hypercoagulable states, such as the following:
    • Lupus anticoagulant and anticardiolipin antibodies
    • Protein C, protein S, and antithrombin III deficiencies
  • Factor V Leiden mutation
  • Creatine kinase, cardiac isoenzymes, and troponin level should be tested in the following persons:
    • All symptomatic patients (eg, with chest pain)
    • Patients with evidence of ischemic changes in the electrocardiogram (ECG; because of the high incidence of concomitant coronary artery disease)7

Imaging Studies

  • Computed tomography (CT) scanning8,9
    • CT scanning usually is the first imaging study performed, because it has a sensitivity of more than 95% when used in the identification intra-axial or extra-axial hemorrhage within the first 24 hours of onset.
    • The disadvantages of CT scanning include a low sensitivity for early ischemia and the presence of significant artifacts caused by the bony structures surrounding the brainstem and cerebellum.
    • Other helpful findings include evidence of infarcts in the thalamus or occipital lobes (implicating involvement of the rostral basilar artery) and evidence that a hyperdense basilar artery is present (suggesting a probable occlusion).10
    • Spiral CT angiography is used further to identify occluded and dolichoectatic vessels.11,12
  • Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA)8,9,13
    • MRI is more sensitive than CT scanning in the identification of ischemia (since bone does not degrade the image). Newer techniques, including flow suppression and the production of diffusion-weighted and perfusion-weighted images, make MRI a very powerful tool for the exclusion of intraparenchymal hemorrhage or edema and for the identification of early and potentially reversible ischemia.14,15
    • MRI and magnetic resonance angiography (MRA) are very helpful in finding occult lesions, such as demyelinating plaques, tumors, vertebrobasilar dolichoectasia, or dissection.16,17,18 MRA has a sensitivity of up to 97% and a specificity of up to 98% when used to identify vertebrobasilar occlusion. A limitation of MRA is its tendency to overestimate the degree of stenosis. This overestimation occurs because the production of a vessel's image in MRA is a based on a flow-related phenomenon; hence, the presence of severe stenosis with significant flow compromise may result in poor visualization of a vessel and cause the MRA scan to resemble vascular occlusion.
  • Transcranial Doppler (TCD)19
    • TCD is used in the evaluation of cerebrovascular disease, but it often is inaccurate. Absence of signal in an initial examination does not necessarily mean occlusion.
    • TCD is helpful for purposes of follow-up once an initial evaluation has demonstrated the lesion. TCD has a sensitivity of 72% and a specificity of 94% in patients with basilar artery disease.

Related eMedicine topic:
Magnetic Resonance Imaging in Acute Stroke

Other Tests

  • Electrocardiography should be performed in all patients on initial evaluation. All patients should be monitored continuously for the first few days. Ischemic changes in the ECG should be investigated further with serum creatine kinase, cardiac isoenzymes, and troponin levels for reasons that include the following:
    • Up to 20% of patients with acute stroke have an arrhythmia.
    • Myocardial infarction occurs in 2-3% of patients.
    • The presence of arrhythmias (eg, atrial fibrillation) has an impact on long-term patient management related to stroke prevention.
  • Echocardiography20 should be considered in the following patients:
    • Those younger than 45 years
    • Those with explained basilar artery occlusion

Findings that may affect management include valvular disorders, vegetations, intramural or extramural thrombi, ventricular aneurisms, cardiac tumors (myxoma), right-to-left shunts, and poor ejection fraction.

Procedures

  • Cerebral (catheter) angiography - While the role of angiography has changed due to the availability of noninvasive imaging modalities (eg, MRI, MRA, TCD), it still is considered the criterion standard for imaging. Catheter cerebral angiography is performed in the following circumstances:
    • In cases when an MRA cannot be carried out because the patient has an absolute contraindication (eg, a pacemaker, metallic implant)
    • When the quality of the noninvasive studies is not satisfactory or when the results of the tests do not explain the clinical findings
    • Angiography should be considered a first-line diagnostic test after a CT scan, once it has been decided that recanalization with thrombolysis should be completed. The most important goal of the workup is to establish the type of vascular lesion and the mechanism of the stroke.

More on Vertebrobasilar Stroke

Overview: Vertebrobasilar Stroke
Differential Diagnoses & Workup: Vertebrobasilar Stroke
Treatment & Medication: Vertebrobasilar Stroke
Follow-up: Vertebrobasilar Stroke
Multimedia: Vertebrobasilar Stroke
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

vertebrobasilar stroke, vertebrobasilar, stroke, vertebrobasilar cerebrovascular accident, vertebrobasilar CVA, ischemic stroke, ischemic attack transient, transient ischemic attack, ischaemic stroke, intracerebral hemorrhages, neurologic deficits, vertebral artery, vertebral arteries, basilar artery, basilar arteries, cerebral artery, cerebral arteries, dysmetria, ataxia, dysarthria, dysphagia, vertigo, nausea, vomiting, nystagmus, unilateral Horner syndrome, brainstem lesions, brain stem lesions, occipital lobe lesions, visual field loss, visuospatialdeficits, hemisphericlesions, cortical deficits, aphasia, cognitive impairments

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Contributor Information and Disclosures

Author

Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Vladimir Kaye, MD is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Physical Medicine and Rehabilitation, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Murray E Brandstater, MBBS, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Association for Academic Psychiatry, California Society of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Canadian Society of Clinical Neurophysiologists, Catholic Medical Association, National Stroke Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, and Royal College of Physicians and Surgeons of the United States
Disclosure: Nothing to disclose.

Medical Editor

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching

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