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Vertebrobasilar Atherothrombotic Disease: Differential Diagnoses & Workup

Author: Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Coauthor(s): Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Contributor Information and Disclosures

Updated: Jun 3, 2008

Differential Diagnoses

Benign Positional Vertigo
Stroke, Hemorrhagic
Dissection, Vertebral Artery
Stroke, Ischemic
Labyrinthitis
Transient Ischemic Attack
Multiple Sclerosis
Vestibular Neuronitis

Other Problems to Be Considered

Aneurysms, vertebrobasilar
Basilar artery dissection
Basilar artery migraine
Posterior fossa tumor
Transtentorial herniation
Vasculitis (involving vertebrobasilar circulation)

Workup

Laboratory Studies

Imaging studies are the primary tools used to confirm a vertebrobasilar atherothrombotic disease (VBATD) diagnosis. They also help exclude differential diagnoses that would preclude such therapies as anticoagulants. Ancillary evaluations, however, are important in the search for other conditions whose signs and symptoms overlap VBATD's complex clinical syndrome. These include the following:

  • CBC count
  • Electrolyte profile
  • BUN level
  • Serum glucose level
  • Erythrocyte sedimentation rate (ESR)
  • Urinalysis
  • Thyroid function testing
  • Venereal disease research labs (VDRL) test
  • Coagulation profile

Imaging Studies

  • CT scanning helps rule out CNS hemorrhage or mass effect secondary to cerebellar infarction. However, CT is not a good choice for detecting brainstem infarctions because of bony interference.
  • MRI is far superior to CT for brainstem and posterior fossa imaging. MRI is more sensitive to small ischemic areas that characterize branch occlusion of the vertebrobasilar circulation. As a result MR is the imaging method of choice for patients with posterior circulation ischemia.
  • Magnetic resonance angiography (MRA) may be as good as cerebral angiography for detecting occlusions and stenoses of the vertebrobasilar circulation, but it may not be as good for quantifying degree of stenosis.
  • Doppler ultrasonography may complement MRA and provide important hemodynamic data on degree of vertebrobasilar stenosis.
  • Transcranial Doppler helps assess and monitor vertebrobasilar patency in patients who have received intraarterial thrombolysis.
  • Chest radiography may be indicated to rule out conditions whose signs and symptoms are similar to those of VBATD.
  • A therapeutic gap is recognized.
    • Diagnostic neuroimaging developments have surpassed therapeutic interventions available for patients with VBATD.
    • Surgery is not an established treatment option for VBATD, in contrast to its value for treating carotid territory ischemia.
    • Invasive techniques such as intraarterial thrombolysis and angioplasty generally are investigational at this time.
    • Specialized neuroimaging (eg, MRI, angiography) has no impact on clinical decision making for the vast majority of patients with VBATD.
    • For imaging patients with uncomplicated VBATD, the American Heart Association recommends CT scanning and duplex ultrasonography of the carotid vessels to search for surgically amenable stenoses.2

Other Tests

  • ECG may be indicated to rule out conditions whose signs and symptoms are similar to those of VBATD.

Procedures

  • Consider a lumbar puncture (LP) when differential diagnosis includes subarachnoid hemorrhage (negative CT scan) or meningoencephalitis.

More on Vertebrobasilar Atherothrombotic Disease

Overview: Vertebrobasilar Atherothrombotic Disease
Differential Diagnoses & Workup: Vertebrobasilar Atherothrombotic Disease
Treatment & Medication: Vertebrobasilar Atherothrombotic Disease
Follow-up: Vertebrobasilar Atherothrombotic Disease
References
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References

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  2. Feinberg WM, Albers GW, Barnett HJ. Guidelines for the management of transient ischemic attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Circulation. Jun 1994;89(6):2950-65. [Medline].

  3. Coull BM, Williams LB, Goldstein LS. Anticoagulants and antiplatelet agents in acute ischemic stroke. Report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a Division of the American Heart Association). Neurology. 2002;59 (1):13-22. [Medline].

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Further Reading

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Keywords

vertebrobasilar atherothrombotic disease, VBATD, vertebrobasilar insufficiency, basilar artery occlusion, lateral medullary infarction, Wallenberg syndrome, stroke, transient ischemic attacks, TIA, vertebrobasilar atherothrombotic disease, vertebrobasilar insufficiency, VBI, labyrinthitis, vestibular neuronitis, benign paroxysmal positional vertigo, brainstem infarction, atherosclerosis, syncope, medial medullary infarct, basilar artery syndrome, subclavian steal syndrome, Horner syndrome, hypertension, diabetes mellitus, smoking, fibromuscular dysplasia, rotational occlusion, Bow hunter's stroke, vertebral artery dissection, vertebrobasilar aneurysm

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Contributor Information and Disclosures

Author

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Royal College of Physicians and Surgeons of Canada, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Clinical Assistant Professor, Residency Program Director, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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