Vertebrobasilar insufficiency

  • Arockia Doss
  • Constantine C. Phatouros
Article

Opinion statement

Vertebrobasilar insufficiency presents with characteristic symptoms and signs due to impaired perfusion of the cerebellum, the brain stem, and the occipital cortex. This may be due to reduced perfusion usually due to atherosclerosis or thromboembolism. Choice of treatment depends on understanding the different underlying pathophysiologic mechanisms. Antiplatelet therapy; reduction of risk factors such as diabetes, hypertension, hypercholesterolemia, and cigarette smoking; and a healthy lifestyle form the first line of management. Systemic anticoagulation in the short term also has a key role in selected cases. In patients with refractory symptoms on maximal medical therapy and underlying focal stenotic lesions, endovascular revascularization using stents and balloon angioplasty may be indicated. Bypass surgery is another option if there are factors that render endovascular therapy unsuitable.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Bamford J, Sandercock P, Dennis M, et al.: Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991, 337:1521–1526.PubMedCrossRefGoogle Scholar
  2. 2.
    Bogousslavsky J, van Melle G, Regli F: The Lausanne Stroke Registry: analysis of 1000 consecutive patients with first stroke. Stroke 1988, 19:1083–1092.PubMedGoogle Scholar
  3. 3.
    Lang E, Afilalo M: Vertebrobasilar atherothrombotic disease. eMedicine [serial online]. http://www.emedicine. com/emerg/topic834.htm.July 2, 2004.Google Scholar
  4. 4.
    British National Formulary: rtPA, Heparin, Clopidogrel, Ticlopidine, Dipyridamole, Atorvastatin, ACE inhibitors and Abciximab. http://www.bnf.org/ bnf/bnf/current/openat/index.htm.Google Scholar
  5. 5.
    Wardlaw JM, del Zoppo G, Yamaguchi T: Thrombolysis for acute ischaemic stroke (Cochrane Review). In The Cochrane Library, Issue 3 (update software). Oxford: 2001.Google Scholar
  6. 6.
    Chimowitz MI, Lynn MJ, Howlett-Smith H, et al.: Comparison of warfarin and aspirin symptomatic intracranial arterial stenosis. N Engl J Med 2005, 352:1305–1316. Randomized comparison of high-dose aspirin with warfarin (INR 2–3) in patients with intracranial major arterial stenosis showed that warfarin was associated with significantly higher rates of adverse events and provided no benefit over aspirin in the long term. However, this does not preclude short-term use of anticoagulants in the acute phase.PubMedCrossRefGoogle Scholar
  7. 7.
    Koroshetz WJ: Warfarin, aspirin and intracranial vascular disease. N Engl J Med 352:1368-1370.Google Scholar
  8. 8.
    Chen ZM, Sandercock P, Pan HC, et al.: Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40,000 randomized patients from the Chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke 2000, 31:1240–1249.PubMedGoogle Scholar
  9. 9.
    Jones L, Griffin S, Palmer S, et al.: Clinical effectiveness and cost-effectiveness of clopidogrel and modifiedrelease dipyridamole in the secondary prevention of occlusive vascular events: a systematic review and economic evaluation. Health Technol Assess 2004, 8(38). http://www.ncchta.org/execsumm/summ838.htm.Google Scholar
  10. 10.
    Diener HC, Bougousslavsky J, Brass LM, et al.: Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomized, double-blind, placebo-controlled trail. Lancet 2004, 364:331–337. Randomized controlled trial comparing aspirin versus aspirin and clopidogrel in high-risk patients showed that combination antiplatelet therapy led to increased hemorrhagic complications long term. However, the data supports the use of combination antiplatelet therapy in the acute setting of TIA.PubMedCrossRefGoogle Scholar
  11. 11.
    A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE steering committee [no authors listed]. Lancet 1996, 348:1329-1339.Google Scholar
  12. 12.
    Diener HC: Secondary prevention of stroke with antiplatelet drugs. Med Klin (Munich) 2004, 99(suppl 1):21–25.Google Scholar
  13. 13.
    Colhoun HM, Betteridge DJ, Durrington PN: Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004, 364:685–696.PubMedCrossRefGoogle Scholar
  14. 14.
    Chalmers J, MacMahon S: Perindopril Protection Against Recurrent Stroke Study (PROGRESS): interpretation and implementation. J Hypertens Suppl 2003, 21(suppl 5):S9-S14.PubMedGoogle Scholar
  15. 15.
    Hass WK, Fields WS, North RR, et al.: Joint study of extracranial arterial occlusion. II. Arteriography techniques, sites, and complications. JAMA 1968, 203:961–968.PubMedCrossRefGoogle Scholar
  16. 16.
    Chastain HD, Campbell MS, Iyer S, et al.: Extracranial vertebral artery stent placement: in-hospital and follow-up results. J Neurosurg 1999, 91:547–552.PubMedGoogle Scholar
  17. 17.
    Jenkins JS, White CJ, Ramee SR, et al.: Vertebral artery stenting. Catheter Cardiovasc Interv 2001, 54:1–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Malek AM, Higashida RT, Phatouros CC, et al.: Treatment of posterior circulation ischaemia with extracranial percutaneous balloon angioplasty and stent placement. Stroke 1999, 30:2073–2085.PubMedGoogle Scholar
  19. 19.
    Thijs VN, Albers GW: Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 2000, 55:490–497.PubMedGoogle Scholar
  20. 20.
    Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA) Study results. The SSYLVIA Study Investigators [no authors listed]. Stroke 2004, 35:1388-1392. Feasibility study on the use of an intracranial stent for cerebral atherosclerotic and vertebral artery origin stenosis showed high rate of success in deployment. A third of all patients had recurrent stenosis. However, approximately 60% of these patients were asymptomatic and the majority was in the ostium of the vertebral artery. A small percentage of patients had short-term postprocedural stroke rate, particularly in the posterior circulation.Google Scholar
  21. 21.
    Qureshi AI: Endovascular treatment of cerebrovascular diseases and intracranial neoplasms. Lancet 2004, 363:804–813.PubMedCrossRefGoogle Scholar
  22. 22.
    Cloud GC, Crawley F, Clifton A, et al.: Vertebral artery origin angioplasty and primary stenting: safety and restenosis rates in a prospective series. J Neurol Neurosurg Psychiatry 2003, 74:586–590.PubMedCrossRefGoogle Scholar
  23. 23.
    Albuquerque FC, Fiorella D, Han P, et al.: A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis. Neurosurgery 2003, 53:607–614.PubMedCrossRefGoogle Scholar
  24. 24.
    Qureshi AI, Ringer AJ, Suri MF, et al.: Acute interventions for ischaemic stroke: present status and future directions. J Endovasc Ther 2000, 7:423–428.PubMedCrossRefGoogle Scholar
  25. 25.
    Phatouros CC, Higashida RT, Malek AM, et al.: Endovascular treatment of noncarotid extracranial cerebrovascular disease. Neurosurg Clin N Am 2000, 11:331–350.PubMedGoogle Scholar
  26. 26.
    Mahon BR, Nesbit GM, Barnwell SL, et al.: North American Clinical Experience with the EKOS MicroLysUS infusion catheter for treatment of embolic stroke. Am J Neuroradiol 2003, 24:534–538.PubMedGoogle Scholar
  27. 27.
    Lutsep HL, Campbell M, Clark WM: EPAR therapy system for treatment of acute stroke: safety study results. Stroke 2001, 32:319b.Google Scholar
  28. 28.
    Levy EI, Hanel RA, Howington JU, et al.: Sirolimuseluting stents in the canine cerebral vasculature: a prospective, randomized, blinded assessment of safety and response. J Neurosurg 2004, 100:688–694.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2006

Authors and Affiliations

  • Arockia Doss
    • 1
  • Constantine C. Phatouros
  1. 1.Department of RadiologyRoyal Prince Alfred HospitalSydneyAustralia

Personalised recommendations