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Vertebrobasilar Atherothrombotic Disease Workup

  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Robert E O'Connor, MD, MPH  more...
Updated: Sep 09, 2014

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

See the list below:

  • 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.
  • CT scanning can also demonstrate a hyperdense basilar artery sign, shown in the image below, in the setting of a suspected posterior circulation stroke.[2] This finding is highly specific but only moderately sensitive. It is also associated with a poor prognosis.
    Hyperdense basilar artery (arrow). Hyperdense basilar artery (arrow).
  • MRI is far superior to CT for brainstem and posterior fossa imaging.[29] 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.
  • Contrast-enhanced magnetic resonance angiography (CE-MRA) and CTA may be as good as cerebral angiography for detecting occlusions and stenoses of the vertebrobasilar circulation, but may not be as good for quantifying degree of stenosis. When comparing CE-MRA and CTA for detection of vertebrobasilar circulation stenosis, both have a high sensitivity and specificity, although CTA is perhaps slightly less than CE-MRA.[31] MRA and angiography images are shown below.
    Magnetic resonance angiography demonstrating the aMagnetic resonance angiography demonstrating the absence of flow in the vertebrobasilar system.
  • Doppler ultrasound (duplex ultrasonography) may complement MRA and provide important hemodynamic data on degree of vertebrobasilar stenosis.[3] Specifically, it is widely used to identify carotid stenosis, but is much less sensitive in the detection of vertebral artery stenosis.[27]
  • Multimodal MRI can provide unique information about the extent and prognosis of smaller infarcts and demonstrate tissue at risk in the ischemic penumbra.
  • Transcranial Doppler helps assess and monitor vertebrobasilar patency in patients who have received intra-arterial 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 now recommends MR imaging in addition to or instead of CT scanning and duplex ultrasonography of the carotid vessels to search for surgically amenable stenoses.[4]

Other Tests

See the list below:

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


See the list below:

Contributor Information and Disclosures

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.


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 is a member of the following medical societies: American College of Emergency Physicians, Royal College of Physicians and Surgeons of Canada, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ryan Wilkie University of Calgary Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

  1. Flossmann E, Rothwell PM. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain. 2003 Sep. 126(Pt 9):1940-54. [Medline].

  2. Goldmakher GV, Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Halpern EF, et al. Hyperdense basilar artery sign on unenhanced CT predicts thrombus and outcome in acute posterior circulation stroke. Stroke. 2009 Jan. 40(1):134-9. [Medline].

  3. Pade O, Eggers J, Schreiber SJ, Valdueza J. Complete basilar artery assessment by transcranial color-coded duplex sonography using the combined transforaminal and transtemporal approach. Ultraschall Med. 2011 Dec. 32 Suppl 2:E63-8. [Medline].

  4. [Guideline] Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 May. 38(5):1655-711. [Medline].

  5. 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].

  6. Brandt T, von Kummer R, Muller-Kuppers M. Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome. Stroke. 1996 May. 27(5):875-81. [Medline].

  7. Webb S, Yashar P, Kan P, Siddiqui AH, Hopkins LN, Levy EI. Treatment and outcomes of acute intracranial vertebrobasilar artery occlusion: one institution's experience. J Neurosurg. 2012 Feb 3. [Medline].

  8. Fintel DJ. Oral antiplatelet therapy for atherothrombotic disease: overview of current and emerging treatment options. Vasc Health Risk Manag. 2012. 8:77-89. [Medline]. [Full Text].

  9. Sivenius J, Riekkinen PJ, Smets P. The European Stroke Prevention Study (ESPS): results by arterial distribution. Ann Neurol. 1991 Jun. 29(6):596-600. [Medline].

  10. International Stroke Trial Collaborative Group. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet. 1997 May 31. 349(9065):1569-81. [Medline].

  11. Whisnant JP, Cartlidge NE, Elveback LR. Carotid and vertebral-basilar transient ischemic attacks: effect of anticoagulants, hypertension, and cardiac disorders on survival and stroke occurrence--a population study. Ann Neurol. 1978 Feb. 3(2):107-15. [Medline].

  12. Macleod MR, Davis SM, Mitchell PJ. Results of a multicentre, randomised controlled trial of intra-arterial urokinase in the treatment of acute posterior circulation ischaemic stroke. Cerebrovasc Dis. 2005. 20(1):12-7. [Medline].

  13. Becker KJ, Purcell LL, Hacke W. Vertebrobasilar thrombosis: diagnosis, management, and the use of intra- arterial thrombolytics. Crit Care Med. 1996 Oct. 24(10):1729-42. [Medline].

  14. Caplan LR. Vertebrobasilar occlusive disease. Stroke: Pathophysiology, Diagnosis and Management. 1992. Vol 1: 549-619.

  15. [Guideline] Culebras A, Kase CS, Masdeu JC. Practice guidelines for the use of imaging in transient ischemic attacks and acute stroke. A report of the Stroke Council, American Heart Association. Stroke. 1997 Jul. 28(7):1480-97. [Medline].

  16. Delaney KA. Bedside diagnosis of vertigo: value of the history and neurological examination. Acad Emerg Med. 2003 Dec. 10(12):1388-95. [Medline].

  17. [Guideline] 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. 1994 Jun. 89(6):2950-65. [Medline].

  18. Froehling DA, Silverstein MD, Mohr DN. The rational clinical examination. Does this dizzy patient have a serious form of vertigo?. JAMA. 1994 Feb 2. 271(5):385-8. [Medline].

  19. Libman RB, Kwiatkowski TG, Hansen MD. Differences between anterior and posterior circulation stroke in TOAST. Cerebrovasc Dis. 2001. 11(4):311-6. [Medline].

  20. Lipinski CA, Swanson ER. Vertebrobasilar distribution stroke mimicking transtentorial herniation. Ann Emerg Med. 1998 May. 31(5):640-2. [Medline].

  21. Ois A, Gomis M, Rodriguez-Campello A, et al. Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke. Stroke. 2008 Jun. 39(6):1717-21. [Medline]. [Full Text].

  22. Phan TG, Wijdicks EF. Intra-arterial thrombolysis for vertebrobasilar circulation ischemia. Crit Care Clin. 1999 Oct. 15(4):719-42, vi. [Medline].

  23. Piechowski-Jozwiak B, Bogousslavsky J. Basilar occlusive disease: the descent of the feared foe?. Arch Neurol. 2004 Apr. 61(4):471-2. [Medline].

  24. Sauvaget E, Kici S, Petelle B. Vertebrobasilar occlusive disorders presenting as sudden sensorineural hearing loss. Laryngoscope. 2004 Feb. 114(2):327-32. [Medline].

  25. Terada T, Higashida RT, Halbach VV. Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries. J Neurol Neurosurg Psychiatry. 1996 Apr. 60(4):377-81. [Medline].

  26. Voetsch B, DeWitt LD, Pessin MS. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2004 Apr. 61(4):496-504. [Medline].

  27. Markus HS, Bart van der Worp H, Rothwell PM. Posterior circulation ischaemic stroke and transient ischaemic attack: diagnosis, investigation, and secondary prevention. Lancet Neurology. 2013. 12:990. [Medline].

  28. Kim JS, Cho KH, Lee H. Isolated labyrinthine infarction as a harbinger of anterior inferior cerebellar artery territory infarction with normal diffusion-weighted brain MRI. Journal of the Neurological Sciences. 2009. 278(1-2):82-4. [Medline].

  29. Schneider JI, Olshaker JS. Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke. Emerg Med Clin North Am. 2012 Aug. 30(3):681-93. [Medline].

  30. Morasch MD. Vertebral Artery Disease. Cronenwett JL and Johnston KW. Rutherford's Vascular Surgery. 8th. Toronto: Saunders; 2014. Chapter 107. [Full Text].

  31. Khan S, Rich P, Clifton A and Markus HS. Noninvasive Detection of Vertebral Artery Stenosis: A Comparison of Contrast-Enhanced MR Angiography, CT Angiography, and Ultrasound. Stroke. 2009. 40(11):3499-3503. [Medline]. [Full Text].

  32. Sarikaya H, Arnold M, Engelter ST, Lyrer PA, Mattle HP, Georgiadis D, et al. Outcomes of intravenous thrombolysis in posterior versus anterior circulation stroke. Stroke. 2011. 42(9):2498-502. [Medline].

  33. Suri MF, Johnston SC. Epidemiology of intracranial stenosis. J Neuroimaging. 2009 Oct. 19 (suppl 1):11S-6S. [Medline].

  34. Markus HS, Khan U, Birns J, Evans A, Kalra L, Rudd AG, et al. Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study. Circulation. 2007 Nov 6. 116(19):2157-64. [Medline].

Vascular territories of the brain.
Diffusion-weighted MRI images showing a right cerebellar infarct.
Magnetic resonance angiography demonstrating the absence of flow in the vertebrobasilar system.
Right vertebral artery angiography showing an occlusion with no flow in the basilar artery.
Angiography performed after intra-arterial thrombolysis and angioplasty showing recanalization and perfusion of the basilar artery and its branches.
Hyperdense basilar artery (arrow).
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