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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
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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]
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Other Tests

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

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Contributor Information and Disclosures
Author

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.

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 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.

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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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