Vertebrobasilar Atherothrombotic Disease Workup

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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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

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Imaging Studies

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  • 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 a Magnetic 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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