Vertebrobasilar insufficiency: Difference between revisions

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{{Vertebrobasilar insufficiency}}


'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
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{{SK}} VBI
{{SK}} Basilar artery insufficiency; Basilar artery ischemia; Basilar artery stenosis; Vertebral artery insufficiency; Vertebral artery ischemia; Vertebral artery stenosis; Vertebrobasilar dolichoectasia; Vertebrobasilar ischemia


== Overview ==
==[[Vertebrobasilar insufficiency overview|Overview]]==
'''Vertebrobasilar insufficiency''' (VBI), or vertebral basilar ischemia, refers to a temporary set of symptoms due to decreased blood flow in the posterior circulation of the brain.  The posterior circulation supplies blood to the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex (responsible for vision).  Therefore, the symptoms due to VBI vary according to which portions of the brain experience significantly decreased blood flow.  In the United States, 25% of strokes (see [[stroke]]) and transient ischemic attacks (see [[transient ischemic attack]]) occur in the vertebrobasilar distribution.  These must be separated from strokes arising from the anterior circulation, which involves the carotid arteries.


==Historical Perspective==
==[[Vertebrobasilar insufficiency historical perspective|Historical Perspective]]==
===Overview===
Vertebrobasilar insufficiency is a pathological hypoperfuse of the posterior circle of brain characterized by an series of symptoms due to insufficient blood flow to the related brain area.The concept “vertebrobasilar insufficiency was first described in 1961 by NIEDERMEYER E.<ref name="pmid13938491">NIEDERMEYER E (1963) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13938491 The electroencephalogram and vertebrobasilar artery insufficiency.] ''Neurology'' 13 ():412-22. PMID: [http://pubmed.gov/13938491 13938491]</ref>Throughout history many renowned researchers and health care professionals have contributed to the understanding, definition, and recognition of vertebrobasilar insufficiency.
===Development of Treatment Strategies===
The first surgical correction of vertebral artery stenosis was published by Crawford and De Bakey in 1958.<ref name="pmid13575180">CRAWFORD ES, DE BAKEY ME, FIELDS WS (1958) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13575180 Roentgenographic diagnosis and surgical treatment of basilar artery insufficiency.] ''J Am Med Assoc'' 168 (5):509-14. PMID: [http://pubmed.gov/13575180 13575180]</ref>  Transposition of the proximal vertebral artery to the common carotid was described by Clark and Perry in 1966.<ref name="pmid5907566">Clark K, Perry MO (1966) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=5907566 Carotid vertebral anastomosis: an alternate technic for repair of the subclavian steal syndrome.] ''Ann Surg'' 163 (3):414-6. PMID: [http://pubmed.gov/5907566 5907566]</ref>  The [[ great saphenous vein|saphenous vein]] was used to bypass vertebral artery origin stenoses during 1970s.<ref name="pmid949261">Berguer R, Andaya LV, Bauer RB (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=949261 Vertebral artery bypass.] ''Arch Surg'' 111 (9):976-9. PMID: [http://pubmed.gov/949261 949261]</ref>  The approach to the distal vertebral artery was first described by Matas<ref name="pmid17859982">Matas R (1893) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17859982 Traumatisms and Traumatic Aneurisms of the Vertebral Artery and Their Surgical Treatment with the Report of a Cured Case.] ''Ann Surg'' 18 (5):477-521. PMID: [http://pubmed.gov/17859982 17859982]</ref>and was used for the treatment of traumatic injury.And in 1978,the [[carotid endarterectomy]] was proved  to produced relief of symptoms in 90% of the patients.<ref name="pmid708258">Rosenthal D, Cossman D, Ledig CB, Callow AD (1978) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?Meagswhile,venous bypass and skull base transposition procedures to revascularize the distal vertebral artery were developed dbfrom=pubmed&retmode=ref&cmd=prlinks&id=708258 Results of carotid endarterectomy for vertebrobasilar insufficiency: an evaluation over ten years.] ''Arch Surg'' 113 (11):1361-4. PMID: [http://pubmed.gov/708258 708258]</ref>  In 1981, Motarjeme et al18 published the first case of vertebral artery origin [[angioplasty]].<ref name="pmid7232739">Motarjeme A, Keifer JW, Zuska AJ (1981) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7232739 Percutaneous transluminal angioplasty of the vertebral arteries.] ''Radiology'' 139 (3):715-7. [http://dx.doi.org/10.1148/radiology.139.3.7232739 DOI:10.1148/radiology.139.3.7232739] PMID: [http://pubmed.gov/7232739 7232739]</ref>  In the recent 30 years, different kinds of surgery was rapidly developed to treat the VBI, such as fenestration, passby surgery, [[angioplasty]].  With the development of interventional techniques, more and more attemps have been made to treat the VBI, but there isn't enough comparative evidence to support the benefit of interventional therapy.


==Classification==
==[[Vertebrobasilar insufficiency classification|Classification]]==
===Overview===
There isn't classification about the VBI yet, but there are three phenotypes of the basilar artery occlusion depending on the modal of initial symptoms.
===Classification===
*phenotype 1: patients present progressive brain stemsymptoms(for example: [[vertigo]], doublevision, dysarthria, [[hemiparesis]], or [[paresthesia]]) without any prodromal symptoms.<ref name="pmid22994219">Lindsberg PJ, Sairanen T, Strbian D, Kaste M (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22994219 Current treatment of basilar artery occlusion.] ''Ann N Y Acad Sci'' 1268 ():35-44. [http://dx.doi.org/10.1111/j.1749-6632.2012.06687.x DOI:10.1111/j.1749-6632.2012.06687.x] PMID: [http://pubmed.gov/22994219 22994219]</ref>
*phenotype 2: patients present nonspecific, such as [[Nausea and Vomiting|nausea]], [[tinnitus]], [[Hearing impairment|hearing loss]], and [[vertigo]], which can precede the onset of the monophasic, progressive deficits by days, but typically by several weeks.<ref name="pmid2389292">Ferbert A, Brückmann H, Drummen R (1990) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2389292 Clinical features of proven basilar artery occlusion.] ''Stroke'' 21 (8):1135-42. PMID: [http://pubmed.gov/2389292 2389292]</ref><ref name="pmid16174929">Baird TA, Muir KW, Bone I (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16174929 Basilar artery occlusion.] ''Neurocrit Care'' 1 (3):319-29. [http://dx.doi.org/10.1385/NCC:1:3:319 DOI:10.1385/NCC:1:3:319] PMID: [http://pubmed.gov/16174929 16174929]</ref>
*phenotype 3: patients present symptoms with onset of severe, often bilateral motor weakness, ophtalmoplegia, and [[coma]].  The patients may have a severe outcome if basilar artery cannot be recanalized fast.<ref name="pmid22994219">Lindsberg PJ, Sairanen T, Strbian D, Kaste M (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22994219 Current treatment of basilar artery occlusion.] ''Ann N Y Acad Sci'' 1268 ():35-44. [http://dx.doi.org/10.1111/j.1749-6632.2012.06687.x DOI:10.1111/j.1749-6632.2012.06687.x] PMID: [http://pubmed.gov/22994219 22994219]</ref>


==Pathophysiology==
==[[Vertebrobasilar insufficiency pathophysiology|Pathophysiology]]==
The vertebral and basilar arteries supply the brainstem, cerebellum, and in most cases also the inferior temporal lobe, occipital lobe, and the thalamus.Variaties of reasons lead to impress the vertebral artery directly or indirectly can reduce the blood stream of posterior circulation of the brain; stimulation caused by the pathologic changes excite the sympathetic nerve and lead to the spasm of vertebral artery finally.Normally,the reduction of blood supply of unilateral veterbrobasilar artery doesn't arouse the ischemia of brain.However,beacuse of the pre-existing maldevelopment,stenosis,embolism or other reasons leads to the reduction of blood supply of contralateral veterbrobasilar artery, patient will suffer the symptoms of ischemia of conrresponding brain area.Sometimes,the reduction of unilateral vertebralbasilar is too serious that the compensation of blood from the unjuried side isn't enough to maintain the normal function of brain,the patient also suffer the symptoms.The sense organs of the visual, vestibular, and propri-
oceptive systems are connected with the cerebellum by way of the vestibular nuclei in
the brainstem. Any disease that interrupts the integration of these 3 systems may give
rise to symptoms of vertigo and disequilibrium.<ref name="pmid22974644">Schneider JI, Olshaker JS (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22974644 Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.] ''Emerg Med Clin North Am'' 30 (3):681-93. [http://dx.doi.org/10.1016/j.emc.2012.06.004 DOI:10.1016/j.emc.2012.06.004] PMID: [http://pubmed.gov/22974644 22974644]</ref>


==Causes==
==[[Vertebrobasilar insufficiency causes|Causes]]==
===Overview===
The causes leading to VBI is primarily the vasulcar ones,like atherosclerosis and cardioembolism,etc.As the vertebral artery is in the cervical vertebra,the
orthopedical reason also contribute to part of the causes.
===Life Threatening Causes===
*Basilar aneurysm


*Stroke caused by arterial embolism
==[[Vertebrobasilar insufficiency differential diagnosis|Differentiating Vertebrobasilar insufficiency from other Diseases]]==


*subarachnoid hemorrhage caused by  vertebrobasilar dissection
==[[Vertebrobasilar insufficiency epidemiology and demographics|Epidemiology and Demographics]]==
===Common Causes===
The most common causes of VBI are cardioembolism,  artery atherosclerosis, and small artery disease.<ref name="pmid24050733">Markus HS, van der Worp HB, Rothwell PM (2013) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=24050733 Posterior circulation ischaemic stroke and transient ischaemic attack: diagnosis, investigation, and secondary prevention.] ''Lancet Neurol'' 12 (10):989-98. [http://dx.doi.org/10.1016/S1474-4422(13)70211-4 DOI:10.1016/S1474-4422(13)70211-4] PMID: [http://pubmed.gov/24050733 24050733]</ref>


===Causes by Organ System===
==[[Vertebrobasilar insufficiency risk factors|Risk Factors]]==


{|style="width:80%; height:100px" border="1"
==[[Vertebrobasilar insufficiency natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[ Intracranial atherosclerosis  ]], [[ vertebral artery dissections    ]],[[maldevelopment or absent of unilateral vertebral artery]],[[arterial embolism ]],[[subclavian steal syndrome  ]],[[rotational VA occlusion]],
 
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| [[Fabry disease ]]
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[physiatric cervical manipulation    ]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| [[Cervical spondylosis  ]],[[degenerative cervical spine changes    ]],[[cervical compressive lesions    ]],[[Cervical tuberculosis]],[[Cervical injury]],[[osteoporosis]]
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"|[[Takayasu disease]][[arteritides]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[Cervical injury]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"|  [[  Postural changes,like head rotation or extension    ]],[[ fibromuscular dysplasia  ]]
|}
 
===Causes in Alphabetical Order===
arterial embolism
 
fibromuscular dysplasia
 
arteritides
 
cervical compressive lesions
 
Cervical injury
 
[[spondylosis|Cervical spondylosis]]
 
[[tuberculosis|Cervical tuberculosis]]
 
degenerative cervical spine changes
 
Intracranial atherosclerosis
 
maldevelopment or absent of unilateral vertebral artery
 
[[Osteoporosis]]
 
Postural changes
 
rotational VA occlusion
 
subclavian steal syndrome
 
[[Takayasu's arteritis]]
 
vertebral artery dissections
 
vertebrobasilar aneurysm*vertebrobasilar aneurysm
 
==Differentiating Vertebral Artery Disease from other Diseases==
It's not easy to make differentia diagnosis between the high-risk posterior circulation ischaemic events and carotid artery events before brain imaging.The Digital subtraction angiography(DSA)is the gold standard to diagosis the VBI.
 
==Epidemiology and Demographics==
The incidence of VBI increases with age and typically occurs in the seventh or eighth decade of life.  Reflecting [[atherosclerosis]], which is the most common cause of VBI, it affects men twice as often as women and is more prevalent in African Americans.  Patients with [[hypertension]], [[diabetes]], smoking, and dyslipidemias also have a higher risk of developing VBI.And intracranial atherosclerosis is more common in individuals with black African<ref name="pmid17967776">Markus HS, Khan U, Birns J, Evans A, Kalra L, Rudd AG et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17967776 Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study.] ''Circulation'' 116 (19):2157-64. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.699785 DOI:10.1161/CIRCULATIONAHA.107.699785] PMID: [http://pubmed.gov/17967776 17967776]</ref>or East Asian ethnic origin than in Caucasian populations<ref name="pmid19807851">Suri MF, Johnston SC (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19807851 Epidemiology of intracranial stenosis.] ''J Neuroimaging'' 19 Suppl 1 ():11S-6S. [http://dx.doi.org/10.1111/j.1552-6569.2009.00415.x DOI:10.1111/j.1552-6569.2009.00415.x] PMID: [http://pubmed.gov/19807851 19807851]</ref>
The stroke caused by VBI account for approximately 20% to 30%21–23
of all
strokes<ref name="pmid22974644">Schneider JI, Olshaker JS (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22974644 Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.] ''Emerg Med Clin North Am'' 30 (3):681-93. [http://dx.doi.org/10.1016/j.emc.2012.06.004 DOI:10.1016/j.emc.2012.06.004] PMID: [http://pubmed.gov/22974644 22974644]</ref>
a study indicates that prev-
alence of >50% vertebral and basilar arterial stenosis,
and vertebrobasilar arterial stenosis was more often
associated with multiple ischemic episodes and a
higher risk of early recurrent stroke.<ref name="pmid19293244">Marquardt L, Kuker W, Chandratheva A, Geraghty O, Rothwell PM (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19293244 Incidence and prognosis of > or = 50% symptomatic vertebral or basilar artery stenosis: prospective population-based study.] ''Brain'' 132 (Pt 4):982-8. [http://dx.doi.org/10.1093/brain/awp026 DOI:10.1093/brain/awp026] PMID: [http://pubmed.gov/19293244 19293244]</ref>
 
==Risk Factors==
The risk factors of VBI is similar to arteriosclerosis and artery embolisom.
Sudden or excessive neck movement might increase the risk of
vertebral artery dissection which might cause the VBI.<ref name="pmid18185906">Kawchuk GN, Jhangri GS, Hurwitz EL, Wynd S, Haldeman S, Hill MD (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18185906 The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation.] ''J Neurol'' 255 (3):371-7. [http://dx.doi.org/10.1007/s00415-008-0667-3 DOI:10.1007/s00415-008-0667-3] PMID: [http://pubmed.gov/18185906 18185906]</ref>
 
==Natural History, Complications and Prognosis==
===Natural History===
Some VBI is caused by the embolus from subclavian artery or atherosclerotic lesions and dissections,etc.Once the  blocked vertebral artery doesn't enough compensation from the contralateral,obviously multiple and multifocal infarcts in the brain stem, cerebellum symptoms will be observed immediately,and quickly develop to a severe outcome.
 
Some patients present nonspecific, such as nausea,tinnitus, hearing loss, and vertigo,which can precede the onset of the monophasic, progressive deficits by days, but typically by several weeks.
 
 
===Prognosis===
The prognosis of VBI vary depend on the severity of symptoms the patients present.
For patients who experience vertebrobasilar transient ischemic attacks, disease identified in the vertebral arteries portends a 30%to 35%risk for stroke during a 5-year period.<ref name="pmid609290">Cartlidge NE, Whisnant JP, Elveback LR (1977) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=609290 Carotid and vertebral-basilar transient cerebral ischemic attacks. A community study, Rochester, Minnesota.] ''Mayo Clin Proc'' 52 (2):117-20. PMID: [http://pubmed.gov/609290 609290]</ref><ref name="pmid6538654">Heyman A, Wilkinson WE, Hurwitz BJ, Haynes CS, Utley CM, Rosati RA et al. (1984) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6538654 Risk of ischemic heart disease in patients with TIA.] ''Neurology'' 34 (5):626-30. PMID: [http://pubmed.gov/6538654 6538654]</ref><ref name="pmid655661">Whisnant JP, Cartlidge NE, Elveback LR (1978) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=655661 Carotid and vertebral-basilar transient ischemic attacks: effect of anticoagulants, hypertension, and cardiac disorders on survival and stroke occurrence--a population study.] ''Ann Neurol'' 3 (2):107-15. [http://dx.doi.org/10.1002/ana.410030204 DOI:10.1002/ana.410030204] PMID: [http://pubmed.gov/655661 655661]</ref>Medical refractory disease of the vertebrobasilar system carries a 5% to 11% risk of stroke or death at 1 year<ref name="pmid12847074">Flossmann E, Rothwell PM (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12847074 Prognosis of vertebrobasilar transient ischaemic attack and minor stroke.] ''Brain'' 126 (Pt 9):1940-54. [http://dx.doi.org/10.1093/brain/awg197 DOI:10.1093/brain/awg197] PMID: [http://pubmed.gov/12847074 12847074]</ref>mortality associated with a posterior circulation stroke is high, ranging from 20% to 30%.<ref name="pmid12847074">Flossmann E, Rothwell PM (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12847074 Prognosis of vertebrobasilar transient ischaemic attack and minor stroke.] ''Brain'' 126 (Pt 9):1940-54. [http://dx.doi.org/10.1093/brain/awg197 DOI:10.1093/brain/awg197] PMID: [http://pubmed.gov/12847074 12847074]</ref>
<ref name="pmid7368245">Jones HR, Millikan CH, Sandok BA (1980) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7368245 Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction.] ''Stroke'' 11 (2):173-7. PMID: [http://pubmed.gov/7368245 7368245]</ref><ref name="pmid13773892">MCDOWELL FH, POTES J, GROCH S (1961) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13773892 The natural history of internal carotid and vertebral-basilar artery occlusion.] ''Neurology'' 11(4)Pt2 ():153-7. PMID: [http://pubmed.gov/13773892 13773892]</ref><ref name="pmid7210071">Patrick BK, Ramirez-Lassepas M, Synder BD (1980) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7210071 Temporal profile of vertebrobasilar territory infarction. Prognostic implications.] ''Stroke'' 11 (6):643-8. PMID: [http://pubmed.gov/7210071 7210071]</ref>
===Complications===
One of the complications is [[vertebral artery dissection]]. It is the development of [[Dissection (medical)|dissection]] (a flap-like tear) in the [[vertebral artery]]. It is commonly associated with [[physical trauma]] but may also develop spontaneously. It is a major cause of [[stroke]] in young people.


==Diagnosis==
==Diagnosis==
The evaluation for VBI starts with a history and physical exam, with great emphasis on the cardiovascular and neurologic exam.  It also includes a work-up to exclude benign conditions (such as [[labyrinthitis]], [[vestibular neuronitis]], and [[benign paroxysmal positional vertigo]]) that have overlapping signs and symptoms.  However, the exact work-up largely depends on the patient’s age and known risk factors.  For middle-aged patients, a cardiovascular risk factor evaluation is important.  This often includes a cholesterol level, lipid profile (see this [http://www.americanheart.org/presenter.jhtml?identifier=183] to determine what your cholesterol level means), ECG, and echocardiogram.  If a person with VBI is under age 45 and has no evidence for atherosclerosis, a work-up for hypercoagulable states (Lupus anticoagulant, [[anti-cardiolipin antibodies]], protein C, protein S, antithrombin III deficiencies) is indicated.
[[Vertebrobasilar insufficiency history and symptoms|History and Symptoms]] | [[Vertebrobasilar insufficiency physical examination|Physical Examination]] | [[Vertebrobasilar insufficiency laboratory findings|Laboratory Findings]] |  [[Vertebrobasilar insufficiency CT|CT]] | [[Vertebrobasilar insufficiency MRI|MRI]] | [[Vertebrobasilar insufficiency other imaging findings|Other Imaging Findings]] | [[Vertebrobasilar insufficiency other diagnostic studies|Other Diagnostic Studies]]
 
Imaging studies are rarely required to diagnose VBI, but sometimes computed tomography (CT) is performed first.  The CT is extremely sensitive in detecting hemorrhage. Duplex ultrasound is widely used to identify carotid stenosis, but is much less sensitive in the detection of
vertebral artery stenosis. The vertebral origin can be often, but not always, visualised, but the more distal segments of the vertebral artery cannot be directly seen However, magnetic resonance imaging (MRI) is superior to the CT in detecting ischemic changes in the vertebrobasilar distribution.  Magnetic resonance angiography (MRA) also can be used to identify vertebrobasilar occlusions, but it can often overestimate the degree of occlusion.
 
 
===Symptoms===
 
[[Vertigo (medical)|Vertigo]] (commonly described as the environment spinning or as if the person is twirling in space) is the most recognizable and quite often the sole symptom of decreased blood flow in the vertebrobasilar distribution.  The vertigo due to VBI rarely is brought on by head turning, which could occlude the ipsilateral vertebral artery and result in decreased blood flow to the brain if the contralateral artery is occluded.  When the vertigo is accompanied by double vision ([[diplopia]]), graying of vision, and blurred vision, patients often go to the [[ophthalmologist]].  If the VBI progresses, there may be weakness of the quadriceps and, to the patient, this is felt as a buckling of the knees.  The patient may suddenly become weak at the knee and crumple (often referred to as a  “drop attack”).  Such a fall can lead to significant head and orthopedic injury, especially in the elderly.   
 
Transient ischemic attacks due to VBI will, by definition, have symptoms resolved within 24 hours.  More often, however, the symptoms are very brief, lasting a few seconds to half an hour.  These symptoms are often provoked by sudden and temporary drops in blood pressure.  Postural changes (see [[orthostatic hypotension]]), such as getting out of bed too quickly or standing up after sitting for extended periods of time, often provoke these attacks.  Exercise of the legs may also bring on the symptoms of VBI.  For the sedentary older subject, going up a flight of stairs or walking the dog may be enough to cause pooling of blood in the legs and a drop in blood pressure in the distal arteries of the head.  Heat and [[dehydration]] may also be contributing causes.
 
Dysarthria should also raise suspicion for VBI.<ref name="pmid18616088">Otto V, Fischer B, Schwarz M, Baumann W, Preibisch-Effenberger R (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18616088 Treatment of vertebrobasilar insufficiency--associated vertigo with a fixed combination of cinnarizine and dimenhydrinate.] ''Int Tinnitus J'' 14 (1):57-67. PMID: [http://pubmed.gov/18616088 18616088]</ref>And there are also some nonspecific symptoms such as unilateral weakness; disturbances of respiration,anomalous hemodynamic change; and disorientation, confusion, and memory loss.The most frequent symptoms were dizziness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%). The most frequent signs were unilateral limb weakness (38%), gait ataxia (31%), unilateral limb ataxia (30%), dysarthria (28%), and nystagmus (24%).<ref name="pmid22083796">Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22083796 Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry.] ''Arch Neurol'' 69 (3):346-51. [http://dx.doi.org/10.1001/archneurol.2011.2083 DOI:10.1001/archneurol.2011.2083] PMID: [http://pubmed.gov/22083796 22083796]</ref>
Some person with vertebralbasilar insufficency are asymptomatic.In a recent hospital-based study of 3717 patients with clinically manifest atherosclerotic arterial disease, 7·6% of patients (95% CI 6·8–8·5) had an asymptomatic vertebral artery origin stenosis of at least 50% or occlusion on duplex ultrasound. <ref name="pmid21852605">Compter A, van der Worp HB, Algra A, Kappelle LJ, Second Manifestations of ARTerial disease (SMART) Study Group (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21852605 Prevalence and prognosis of asymptomatic vertebral artery origin stenosis in patients with clinically manifest arterial disease.] ''Stroke'' 42 (10):2795-800. [http://dx.doi.org/10.1161/STROKEAHA.110.612903 DOI:10.1161/STROKEAHA.110.612903] PMID: [http://pubmed.gov/21852605 21852605]</ref>
===Physical Examination===
Physical examination of VBI isn't enough to diagnosis the disease.Normally,phsician can take several items below:
 
*Vital signs:In some cases, pulses and blood pressure should be checked in both arms. Most patients with subclavian steal syndrome, which can also cause vertebrobasilar artery insufficiency, have pulse or systolic blood pressure differences between the two arms<ref name="pmid22974644">Schneider JI, Olshaker JS (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22974644 Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.] ''Emerg Med Clin North Am'' 30 (3):681-93. [http://dx.doi.org/10.1016/j.emc.2012.06.004 DOI:10.1016/j.emc.2012.06.004] PMID: [http://pubmed.gov/22974644 22974644]</ref>
*auscultated on neck:The vertebral artery bruitscan be found by auscultated,which suggest atherosclerosis.
*eyes:Positional nystagmus, induced by rapidly changing the position of the head,strongly suggests an organic vestibular disorder caused by central nervous system cause like VBI.internuclear ophthalmoplegia,unreactive pupils, skew deviation, hemianopia, and cortical blindness suggests an vertebrobasilar ischemia.<ref name="pmid22083796">Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22083796 Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry.] ''Arch Neurol'' 69 (3):346-51. [http://dx.doi.org/10.1001/archneurol.2011.2083 DOI:10.1001/archneurol.2011.2083] PMID: [http://pubmed.gov/22083796 22083796]</ref>
*Positional testing:If no nystagmus was observed, we can choose the positional testing.In the Hallpike maneuver, patients are moved quickly from an upright seated position to a supine position and the head is turned to one side and extended (to a head-down posture) approximately 30 from the horizontal plane off the end of the stretcher. The eyes should be observed for nystagmus, and patients should be queried for the occurrence of symptoms.This test should be repeated with the head turned to the other side.<ref name="pmid22974644">Schneider JI, Olshaker JS (2012) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22974644 Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.] ''Emerg Med Clin North Am'' 30 (3):681-93. [http://dx.doi.org/10.1016/j.emc.2012.06.004 DOI:10.1016/j.emc.2012.06.004] PMID: [http://pubmed.gov/22974644 22974644]</ref> This test should be performed with caution because of the risk of suddenly dropping of atheromatous plaques.
*other:Some patients are obseved to have right arm weakness and expressive aphasia.
 
===Laboratory Finding===
 
The patients suffered the VBI don't present speciafic laboratory findings.As the main cause of VBI is atherosclerosis and artery embolism,so corrsponding laboratory findings will be obtained.In some uncommom reason caused VBI,specific results appear.for exsample, the abnormal galactosidase activity level in Fabry's disease.
 
====CT====
 
The normal CT can diagnose subarachnoid hemorrhage following the intracranial vertebral artery dissection,but can't provide enough definition to the artery. The contrast CT (CTA) has high sensitivity (94%) and specificity (95%) to make a correct diagnosis compared against the DSA.<ref name="pmid12127847">Long A, Lepoutre A, Corbillon E, Branchereau A (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12127847 Critical review of non- or minimally invasive methods (duplex ultrasonography, MR- and CT-angiography) for evaluating stenosis of the proximal internal carotid artery.] ''Eur J Vasc Endovasc Surg'' 24 (1):43-52. PMID: [http://pubmed.gov/12127847 12127847]</ref>And some researchs reveal that the CT-baesd score can be used in predicting the final infarct size<ref name="pmid19643923">Puetz V, Sylaja PN, Hill MD, Coutts SB, Dzialowski I, Becker U et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19643923 CT angiography source images predict final infarct extent in patients with basilar artery occlusion.] ''AJNR Am J Neuroradiol'' 30 (10):1877-83. [http://dx.doi.org/10.3174/ajnr.A1723 DOI:10.3174/ajnr.A1723] PMID: [http://pubmed.gov/19643923 19643923]</ref> and also for a prognostic assesment early ischemic injury in basilar artery occllusion.<ref name="pmid19643923">Puetz V, Sylaja PN, Hill MD, Coutts SB, Dzialowski I, Becker U et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19643923 CT angiography source images predict final infarct extent in patients with basilar artery occlusion.] ''AJNR Am J Neuroradiol'' 30 (10):1877-83. [http://dx.doi.org/10.3174/ajnr.A1723 DOI:10.3174/ajnr.A1723] PMID: [http://pubmed.gov/19643923 19643923]</ref><ref name="pmid18768716">Cho TH, Nighoghossian N, Tahon F, Némoz C, Hermier M, Salkine F et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18768716 Brain stem diffusion-weighted imaging lesion score: a potential marker of outcome in acute basilar artery occlusion.] ''AJNR Am J Neuroradiol'' 30 (1):194-8. [http://dx.doi.org/10.3174/ajnr.A1278 DOI:10.3174/ajnr.A1278] PMID: [http://pubmed.gov/18768716 18768716]</ref><ref name="pmid18480603">Renard D, Landragin N, Robinson A, Brunel H, Bonafe A, Heroum C et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18480603 MRI-based score for acute basilar artery thrombosis.] ''Cerebrovasc Dis'' 25 (6):511-6. [http://dx.doi.org/10.1159/000131668 DOI:10.1159/000131668] PMID: [http://pubmed.gov/18480603 18480603]</ref><ref name="pmid20562433">Terasawa Y, Kimura K, Iguchi Y, Kobayashi K, Aoki J, Shibazaki K et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20562433 Could clinical diffusion-mismatch determined using DWI ASPECTS predict neurological improvement after thrombolysis before 3 h after acute stroke?] ''J Neurol Neurosurg Psychiatry'' 81 (8):864-8. [http://dx.doi.org/10.1136/jnnp.2009.190140 DOI:10.1136/jnnp.2009.190140] PMID: [http://pubmed.gov/20562433 20562433]</ref>
 
====MRI====
The CE-MRA(Contrast-enhanced magnetic resonance angiography)had the highest sensitivity and specificity  compared against the gold standard of intra-arterial angiography.CE-MRA offers better  visualisation of the extracranial vertebral system than non-contrast MRA.
 
===DSA===
The digital subtraction angiography(DSA)is the gold stardard to diagnose the VBI.


==Treatment==
==Treatment==
Patients should discuss with their physician possible causes for their VBI symptoms.  As discussed above, postural changes, exercise, and dehydration are some of the likely culprits.  Treatment usually involves lifestyle modifications.  For example, if VBI is attributed mainly to postural changes, patients are advised to slowly rise to standing position after sitting for a long period of time.  An appropriate exercise regimen for each patient can also be designed in order to avoid the excessive pooling of blood in the legs.  Dehydrated patients are often advised to increase their water intake, especially in hot, dry climates.  Finally, when applicable, patients are often advised to stop smoking and to control their hypertension, diabetes, and cholesterol level. 
[[Vertebrobasilar insufficiency medical therapy|Medical Therapy]] | [[Vertebrobasilar insufficiency surgery|Surgery]] | [[Vertebrobasilar insufficiency primary prevention|Primary Prevention]] | [[Vertebrobasilar insufficiency secondary prevention|Secondary Prevention]] | [[Vertebrobasilar insufficiency cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Vertebrobasilar insufficiency future or investigational therapies|Future or Investigational Therapies]]


In the event that a patient suffers a “drop attack,” and especially for the elderly population, the most important action is to be evaluated for associated head or other injuries.  To prevent drop attacks, patients are advised to “go to the ground” before the knees buckle and shortly after feeling dizzy or experiencing changes in vision.  Patients should not be concerned about the social consequences of suddenly sitting on the floor, whether in the mall or sidewalk, as such actions are important in preventing serious injuries.   
==Case Studies==
[[Vertebrobasilar insufficiency case study one|Case #1]]


Sometimes, to prevent further occlusion of blood vessels, patients are started on an antiplatelet agent (aspirin, clopidogrel, or aspirin/dipyridamole) or sometimes an anticoagulant (warfarin) once hemorrhage has been excluded with imaging.
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For treatment of vertebrobasilar stenosis due to atherosclerosis, researchers from Stanford University found that intracranial angioplasty can be performed with an annual stroke rate in the territory of treatment of 3.2% and 4.4% for all strokes, including periprocedural events. Randomized control trials need to be performed.
 
Researchers from Poland found that the Low level laser therapy (LLLT) is a very useful treatment of patient with VBI, The main reason for improvement in global stability, balance, and other VBI symptoms is better blood perfusion.Significant improvement after therapy in headache (p=0.0005), vertigo (p<0.0000), and tinnitus (p=0.0387)  and a tendency towards improved stability in all parameterswas  was observed<ref name="pmid21873949">Lukowicz M, Zalewski P, Bulatowicz I, Buszko K, Klawe JJ (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21873949 The impact of laser irradiation on global stability in patients with vertebrobasilar insufficiency: a clinical report.] ''Med Sci Monit'' 17 (9):CR517-22. PMID: [http://pubmed.gov/21873949 21873949]</ref>.
 
===Pharmacotherapy===
Aspirin and other antiplatelet drugs have been used to treat vertebrobasilar
disease,however,none of the drug used in the treatment of VBI has been evaluated in the ramdomized controlled trials.
For patients with acute ischemic syndromes that
involve the vertebral artery territory and angiographic
evidence of thrombus in the extracranial portion of the
vertebral artery, anticoagulation is generally recom-
mended for at least 3 months, whether or not thrombo-
lytic therapy is used initially<ref name="pmid15972868">Savitz SI, Caplan LR (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15972868 Vertebrobasilar disease.] ''N Engl J Med'' 352 (25):2618-26. [http://dx.doi.org/10.1056/NEJMra041544 DOI:10.1056/NEJMra041544] PMID: [http://pubmed.gov/15972868 15972868]</ref><ref name="pmid12777203">Caplan LR (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12777203 Atherosclerotic Vertebral Artery Disease in the Neck.] ''Curr Treat Options Cardiovasc Med'' 5 (3):251-256. PMID: [http://pubmed.gov/12777203 12777203]</ref><ref name="pmid16988872">Canyigit M, Arat A, Cil BE, Sahin G, Turkbey B, Elibol B (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16988872 Management of vertebral stenosis complicated by presence of acute thrombus.] ''Cardiovasc Intervent Radiol'' 30 (2):317-20. [http://dx.doi.org/10.1007/s00270-006-0016-9 DOI:10.1007/s00270-006-0016-9] PMID: [http://pubmed.gov/16988872 16988872]</ref><ref name="pmid16197822">Eckert B (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16197822 Acute vertebrobasilar occlusion: current treatment strategies.] ''Neurol Res'' 27 Suppl 1 ():S36-41. [http://dx.doi.org/10.1179/016164105X25324 DOI:10.1179/016164105X25324] PMID: [http://pubmed.gov/16197822 16197822]</ref>The WASID (War-
farin versus Aspirin for Symptomatic Intracranial Dis-
ease) trial found aspirin and warfarin to be equally
efficacious after initial noncardioembolic ischemic
stroke<ref name="pmid17030766">Kasner SE, Lynn MJ, Chimowitz MI, Frankel MR, Howlett-Smith H, Hertzberg VS et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17030766 Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID.] ''Neurology'' 67 (7):1275-8. [http://dx.doi.org/10.1212/01.wnl.0000238506.76873.2f DOI:10.1212/01.wnl.0000238506.76873.2f] PMID: [http://pubmed.gov/17030766 17030766]</ref><ref name="pmid10953174">Benesch CG, Chimowitz MI (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10953174 Best treatment for intracranial arterial stenosis? 50 years of uncertainty. The WASID Investigators.] ''Neurology'' 55 (4):465-6. PMID: [http://pubmed.gov/10953174 10953174]</ref>
Ticlopidine was superior to aspirin for
secondary prevention of ischemic events in patients
with symptomatic posterior circulation disease.<ref name="pmid1734290">Grotta JC, Norris JW, Kamm B (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1734290 Prevention of stroke with ticlopidine: who benefits most? TASS Baseline and Angiographic Data Subgroup.] ''Neurology'' 42 (1):111-5. PMID: [http://pubmed.gov/1734290 1734290]</ref>
 
===Surgery and Device Based Therapy===
Operations are rarely performed to treat vertebral ar-
tery occlusive disease, and no randomized trials have
addressed operative procedures for posterior cerebral
circulation disease, but studies of surgical treatment
have demonstrated the feasibility of endarterectomy
and vessel reconstruction<ref name="pmid21288680">Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21288680 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery.] ''J Am Coll Cardiol'' 57 (8):1002-44. [http://dx.doi.org/10.1016/j.jacc.2010.11.005 DOI:10.1016/j.jacc.2010.11.005] PMID:[http://pubmed.gov/21288680 21288680]</ref>
====Indications for Surgery====
There isn't guideline about the indication for surgery accepted by most reseachers.But some researchers suggest that:
*The minimal stenosis extent to meet the reconstruction surgery is
*1.stenosis 60% diameter in both vertebral arteries if both are patent and complete
*2.the same degree of stenosis in the dominant vertebral artery if the opposite vertebral artery is hypoplastic,ends in a posteroinferior cerebellar artery, or is occluded<ref name="pmid21718929">Lee CJ, Morasch MD (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21718929 Treatment of vertebral disease: appropriate use of open and endovascular techniques.] ''Semin Vasc Surg'' 24 (1):24-30. [http://dx.doi.org/10.1053/j.semvascsurg.2011.03.003 DOI:10.1053/j.semvascsurg.2011.03.003] PMID: [http://pubmed.gov/21718929 21718929]</ref>
 
In appropriately selected patients,if the patients suffer the atherosclerosis
 
**If the lesion locates at the origin,we can choose:
 
***1. trans-subclavian vertebral endarterectomy.
 
***2. transposition of the vertebral artery to the ipsilateral common carotid artery
 
***3. reimplantation of the vertebral artery with vein graft extension to the subclavian artery
 
**If the lesion invades the distal part,we can choose
 
***1. trans-subclavian vertebral endarterectomy
 
***2. anastomosis of the principal trunk of the external carotid artery to the vertebral artery
 
===The Interventional Therapy===
Some reports suggest that the endovasuclar treatment have a high technical success rate(95%)<ref name="pmid15846607">Coward LJ, Featherstone RL, Brown MM (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15846607 Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis.] ''Cochrane Database Syst Rev''  (2):CD000516. [http://dx.doi.org/10.1002/14651858.CD000516.pub2 DOI:10.1002/14651858.CD000516.pub2] PMID: [http://pubmed.gov/15846607 15846607]</ref>,but meanwhile,it has a high rate of restenosis.The elute stent is believed to be the resotion for decreasing the in-stent restenosis rate.<ref name="pmid20197579">Ogilvy CS, Yang X, Natarajan SK, Hauck EF, Sun L, Lewis-Mason L et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20197579 Restenosis rates following vertebral artery origin stenting: does stent type make a difference?] ''J Invasive Cardiol'' 22 (3):119-24. PMID: [http://pubmed.gov/20197579 20197579]</ref>No matter what kind of stents used to treat the VBI,there isn't enough evidence to support the safety and effectiveness.In recent years,the intravenous thrombolysis(IVT)and intra-arterial thrombolysis(IAT)and mechanical thrombectomy are developed to treat the embolism of vertebrobasilar artery,but still need the ramdom control trials to prove the safety and  effectiveness.
 
==2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 |doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }}</ref>==
===Vascular Imaging in Patients with Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 |pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Noninvasive imaging by [[CTA]] or [[MRA]] for detection of vertebral artery disease should be part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation and those with [[subclavian steal syndrome]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with asymptomatic bilateral carotid occlusions or unilateral [[carotid artery]] occlusion and incomplete [[circle of Willis]] should undergo noninvasive imaging for detection of vertebral artery obstructive disease. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients whose symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended rather than ultrasound imaging for evaluation of the vertebral arteries. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with symptoms of posterior cerebral or cerebellar ischemia, serial noninvasive imaging of the extracranial vertebral arteries is reasonable to assess the progression of atherosclerotic disease and exclude the development of new lesions. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with posterior cerebral or cerebellar ischemic symptoms who may be candidates for [[revascularization]], catheter-based contrast angiography can be useful to define vertebral artery pathoanatomy when noninvasive imaging fails to define the location or severity of stenosis. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients who have undergone vertebral artery revascularization, serial noninvasive imaging of the extracranial vertebral arteries is reasonable at intervals similar to those for carotid revascularization. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
===Management of Atherosclerotic Risk Factors in Patients with Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124| issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Medical therapy and lifestyle modification to reduce atherosclerotic risk are recommended in patients with vertebral atherosclerosis according to the standards recommended for those with extracranial carotid atherosclerosis<ref name="pmid12485966">{{cite journal |author= |title=Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report|journal=Circulation |volume=106 |issue=25 |pages=3143–421 |year=2002 |month=December |pmid=12485966 |doi= |url=}}</ref><ref name="pmid9514413">{{cite journal |author=Ginsberg HN, Kris-Etherton P, Dennis B, ''et al.'' |title=Effects of reducing dietary saturated fatty acids on plasma lipids and lipoproteins in healthy subjects: the DELTA Study, protocol 1|journal=Arterioscler. Thromb. Vasc. Biol. |volume=18 |issue=3 |pages=441–9 |year=1998 |month=March |pmid=9514413 |doi= |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In the absence of contraindications, patients with [[atherosclerosis]] involving the vertebral arteries should receive[[antiplatelet therapy]] with [[aspirin]] (75 to 325 mg daily) to prevent [[MI]] and other ischemic events<ref name="pmid11786451">{{cite journal |author= |title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients |journal=BMJ |volume=324 |issue=7329|pages=71–86 |year=2002 |month=January |pmid=11786451 |pmc=64503 |doi= |url=}}</ref><ref name="pmid8298418">{{cite journal |author= |title=Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration |journal=BMJ |volume=308 |issue=6921 |pages=81–106 |year=1994 |month=January |pmid=8298418 |pmc=2539220 |doi= |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Antiplatelet drug therapy is recommended as part of the initial management for patients who sustain ischemic stroke or TIA associated with extracranial vertebral atherosclerosis. Aspirin (81 to 325 mg daily), the combination of [[aspirin]] plus extended-release [[dipyridamole]] (25 and 200 mg twice daily, respectively), and [[clopidogrel]] (75 mg daily) are acceptable options. Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies<ref name="pmid18322260">{{cite journal |author=Adams RJ, Albers G, Alberts MJ, ''et al.'' |title=Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack |journal=Stroke |volume=39|issue=5 |pages=1647–52 |year=2008 |month=May |pmid=18322260 |doi=10.1161/STROKEAHA.107.189063 |url=}}</ref><ref name="pmid11786451">{{cite journal |author= |title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients |journal=BMJ |volume=324 |issue=7329|pages=71–86 |year=2002 |month=January |pmid=11786451 |pmc=64503 |doi= |url=}}</ref><ref name="pmid8918275">{{cite journal |author= |title=A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee |journal=Lancet |volume=348 |issue=9038 |pages=1329–39 |year=1996|month=November |pmid=8918275 |doi= |url=}}</ref><ref name="pmid15276392">{{cite journal |author=Diener HC, Bogousslavsky J, Brass LM, ''et al.'' |title=Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial|journal=Lancet |volume=364 |issue=9431 |pages=331–7 |year=2004 |pmid=15276392 |doi=10.1016/S0140-6736(04)16721-4 |url=}}</ref><ref name="pmid8981292">{{cite journal |author=Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A |title=European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke|journal=J. Neurol. Sci. |volume=143 |issue=1-2 |pages=1–13 |year=1996 |month=November |pmid=8981292 |doi= |url=}}</ref><ref name="pmid18753638">{{cite journal |author=Sacco RL, Diener HC, Yusuf S, ''et al.'' |title=Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke |journal=N. Engl. J. Med. |volume=359 |issue=12|pages=1238–51 |year=2008 |month=September |pmid=18753638 |pmc=2714259 |doi=10.1056/NEJMoa0805002 |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with atherosclerosis of the extracranial vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including those with allergy to aspirin, either clopidogrel (75 mg daily) or [[ticlopidine]] (250 mg twice daily) is a reasonable alternative. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
==References==
{{Reflist|2}}
 
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Cardiovascular diseases]]
[[Category:Cardiovascular diseases]]
[[Category:Disease]]
[[Category:Neurological disorders]]
[[Category:Neurological disorders]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Mature chapter]]
[[Category:Disease]]

Latest revision as of 16:39, 9 December 2013

Vertebrobasilar insufficiency

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Basilar artery insufficiency; Basilar artery ischemia; Basilar artery stenosis; Vertebral artery insufficiency; Vertebral artery ischemia; Vertebral artery stenosis; Vertebrobasilar dolichoectasia; Vertebrobasilar ischemia

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