Vertebrobasilar Atherothrombotic Disease Treatment & Management

Updated: Oct 05, 2016
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Robert E O'Connor, MD, MPH  more...
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Treatment

Emergency Department Care

Vertebrobasilar atherothrombotic disease (VBATD) management in the emergency department (ED) varies on the basis of the patient's symptoms and condition.

  • For patients with VBATD who have experienced ischemic infarcts, management falls into 2 major categories: supportive measures and interventions to reestablish patency in the infarct-related artery or to prevent occlusion of a vessel at risk for atherothrombotic or embolic occlusion.

  • Airway issues must be addressed in patients with brainstem infarction resulting from VBATD.

    • Compromise of ninth and tenth cranial nerves can blunt the gag reflex and inhibit even a conscious or awake patient from handling secretions effectively.

    • Secure the airway of patient with an unstable course or severe deficits before starting prolonged diagnostic imaging studies.

  • Patients who present to the ED with ischemic stroke are often hypertensive, even in the absence of premorbid blood pressure elevations.

    • Given the autoregulatory curve's tendency to shift to the right during hypertension, most authors caution against lowering the blood pressure in the first 24-48 hours after onset of stroke.

    • A precipitous drop in blood pressure can have a significant impact on cerebral perfusion pressure.

    • Consider antihypertensive medication only in cases of concomitant hypertensive emergency (ongoing end-organ damage), mean arterial pressure (MAP) greater than 130 mm Hg, or systolic blood pressure greater than 220 mm Hg.

  • Because most patients with significant neurologic symptoms are denied oral intake until swallowing mechanisms are evaluated, goals of intravenous fluid therapy are to provide isotonic hydration and to avoid hyperglycemia, which appears to exacerbate neuronal injury in stroke.

  • Treat vomiting with antiemetics; vomiting may be severe in some brainstem infarctions.

  • If a hemorrhagic lesion has been excluded, patients with VBATD are treated with antiplatelet agents or, in certain circumstances, an anticoagulant such as warfarin (see Medication). [5] Reperfuse the infarct-related artery by intra-arterial thrombolysis or percutaneous transluminal angioplasty (see Consultations).

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Consultations

See the list below:

  • Neurologist

  • Neurosurgeon: Consultation with a neurosurgeon is indicated for surgical evacuation of cerebellar hemorrhages and to manage cerebellar infarction complicated by hydrocephalus.

  • Interventional neuroradiologist

    • Intra-arterial thrombolysis: The high mortality rate associated with basilar artery occlusion and resulting brainstem infarction has prompted research into reperfusion therapy via intra-arterial infusion of thrombolytic agents (see Medication). Several case series and small randomized controlled trials have shown promise with regards to recanalization and improved clinical outcomes in basilar artery occlusion and vertebrobasilar stroke. [6, 7] Prethrombolysis and postthrombolysis angiograms are shown below.

      Right vertebral artery angiography showing an occl Right vertebral artery angiography showing an occlusion with no flow in the basilar artery.
      Angiography performed after intra-arterial thrombo Angiography performed after intra-arterial thrombolysis and angioplasty showing recanalization and perfusion of the basilar artery and its branches.
    • Percutaneous transluminal cerebral angioplasty: Increasingly, investigators have described successful dilation of high-grade vertebral artery stenoses in patients with VBATD who did not respond to medical therapy. Although this approach is not without risk (rate of stroke as high as 40% in some series), other studies have described 80% success rates in restoring flow and eliminating symptoms.

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