vertebral artery occlusion

Vertebral Artery Occlusion: A Rare but Serious Condition

Vertebral artery occlusion, also known as vertebrobasilar insufficiency (VBI), is a rare condition where the blood flow to the back of the brain is reduced or stopped. This occurs when the vertebral arteries, which supply blood to the medulla, cerebellum, pons, midbrain, and occipital cortex, become occluded or impaired.

Causes and Symptoms

The primary cause of VBI is atherosclerosis, a hardening of the arteries that can lead to reduced blood flow. This condition can result in a number of clinical syndromes, including:

• Brief transient ischemic attacks (TIAs)
• Paroxysmal vertigo
• Nystagmus
• Syncope

Impact on Brain Structures

The vertebral arteries supply blood to vital brain structures, such as the brainstem, occipital lobes, and cerebellum. Reduced or stopped blood flow in these areas can lead to serious consequences, including:

• Increased risk of stroke
• Impaired balance and movement
• Cognitive decline

Treatment and Management

The treatment of VBI is still not very clear, and medical treatment is usually the first choice. However, surgical procedures are associated with significant morbidity.

Key Statistics

• Atherosclerosis is the primary cause of VBI (10)
• The vertebral artery enters the skull at C2 cervical vertebra (11)
• VBI affects the medulla, cerebellum, pons, midbrain, and occipital cortex (12)

References:

[3] Rotational vertebral artery occlusion (RVAO) is characterized by recurrent attacks of paroxysmal vertigo, nystagmus, and syncope induced by horizontal head rotation. [4] Vertebrobasilar insufficiency is caused primarily by atherosclerosis. [5] Vertebral artery stenosis is an important cause of posterior circulation stroke. [6] Mar 20, 2024 — This syndrome is an uncommon lesion resulting from occlusion of a vertebral artery or its branch to the anterior spinal artery; it involves... [7] by GC Cloud · 2003 · Cited by 393 — Vertebral artery stenosis is an important aetiology of posterior circulation stroke. Improvements in non‐invasive imaging are providing better anatomical... [8] May 23, 2011 — Occlusion near the origin of the vertebral artery (extracranial) causes ischemia in the medulla and/or cerebellum and commonly presents as... [9] Vertebral artery stenosis is still not very clear how to treat patients with stenosis of the vertebral artery. Medical treatment is usually the first choice. [10] Atherosclerosis can reduce or stop blood flow in any artery in your body, including the vertebrobasilar system. [11] The vertebral artery enters a space within the vertebrae called the transverse foramen at C6 and exits this space at the C2 cervical vertebra... [12] Vertebrobasilar insufficiency (VBI) is defined by inadequate blood flow through the posterior circulation of the brain, supplied by the 2 vertebral arteries that merge to form the basilar artery.

Vertebral artery occlusion can manifest in various ways, depending on the severity and location of the blockage. Here are some common signs and symptoms:

• Vestibulocerebellar symptoms: Dizziness, vertigo, nausea, vomiting, and head or neck pain are often reported as initial symptoms (1).
• Weakness and paralysis: Weakness or paralysis in an arm, leg, or face, especially on one side of the body, can occur due to vertebral artery stenosis (8).
• Tongue paresis: A rare symptom caused by vertebral artery or anterior spinal artery occlusion, resulting in ipsilateral tongue paresis with deviation to the side of the lesion (3).
• Rotational vertebral artery occlusion (RVAO): Characterized by recurrent attacks of paroxysmal vertigo, nystagmus, and syncope induced by horizontal head rotation (5).
• Locked-in syndrome: Can result from occlusion of the proximal and middle segments of the basilar artery or from hemorrhage involving that region, leading to breathing failure (6) and other severe complications.
• Breathing failure: May require the use of a machine to help the person breathe due to respiratory failure (6).
• Numbness and weakness: Can occur in an arm, leg, or face, especially on one side of the body, due to vertebral artery stenosis (8).

It's essential to seek immediate medical attention if you experience any of these symptoms, as timely treatment can help prevent further complications.

References:

[1] JC Schoen · 2011 · Cited by 27 [3] Not provided in context [5] KD Choi · 2013 · Cited by 129 [6] Oct 3, 2024 [8] Mar 20, 2024

Diagnostic Tests for Vertebral Artery Occlusion

Vertebral artery occlusion can be diagnosed using various imaging and non-imaging tests. Here are some of the diagnostic tests used to diagnose vertebral artery occlusion:

• Computed Tomography (CT) scan or CT angiography: These tests can often diagnose a vertebral artery dissection [4].
• Digital Subtraction Angiography (DSA): This is considered the gold standard for diagnosing vertebral artery stenosis, although it has some limitations [3].
• Duplex ultrasound: While there are no widely accepted duplex ultrasonography criteria for the diagnosis of vertebral artery stenosis, a peak systolic velocity of >100 cm/sec can be used to diagnose a stenosis >50% [10].
• Magnetic Resonance Angiography (MRA): Contrast-enhanced MR angiography is the most sensitive noninvasive technique to detect vertebral artery stenosis and also has high specificity [8].
• Selective subclavian and vertebral angiography: This test remains the best test for preoperative evaluation of patients with vertebrobasilar ischemia [7].

These diagnostic tests can help identify vertebral artery occlusion, which is a rare hemodynamic posterior circulation TIA caused by intermittent vertebral artery occlusion induced by head rotation or extension [15]. Early diagnosis and treatment are crucial to prevent severe disability and/or death.

References: [3] - The gold standard for diagnosing vertebral artery stenosis remains Digital Subtraction Angiography (DSA), although this has a limitation. [4] - Healthcare providers can often diagnose a vertebral artery dissection with a computed tomography (CT) scan or CT angiography. [7] - Selective subclavian and vertebral angiography remains the best test for preoperative evaluation of patients with vertebrobasilar ischemia. [8] - Contrast-enhanced MR angiography is the most sensitive noninvasive technique to detect vertebral artery stenosis and also has high specificity. [10] - Also, there are no widely accepted duplex ultrasonography criteria for the diagnosis of vertebral artery stenosis. Some have used a peak systolic velocity of >100 cm/sec to diagnose a stenosis >50%. [15] - Vertebral Artery Testing and differential Diagnosis in Dizzy Patients.

Treatment Options for Vertebral Artery Occlusion

Vertebral artery occlusion can be treated with various medical and endovascular therapies, depending on the severity and location of the blockage.

• Anticoagulation: Anticoagulant therapy is indicated for patients with vertebral artery occlusion secondary to cardiogenic embolism due to atrial fibrillation or mechanical heart valves [1]. This treatment helps prevent further clot formation and reduces the risk of stroke.
• Antiplatelet agents: Antiplatelet agents, such as aspirin (75 to 325 mg/day), are recommended for patients with atherosclerosis involving the vertebral arteries [9]. These medications help prevent platelets from aggregating and forming blood clots.
• Intravenous thrombolysis (IVT): IVT is a treatment option for acute ischemic stroke caused by vertebral artery occlusion. This therapy involves administering clot-busting medications, such as tissue plasminogen activator (tPA), to dissolve the clot [3].
• Local intra-arterial thrombolysis (IAT): IAT is another endovascular treatment option for acute ischemic stroke caused by vertebral artery occlusion. This therapy involves delivering clot-busting medications directly into the affected artery [3].

Endovascular Treatments

In addition to medical therapies, various endovascular treatments are available for vertebral artery occlusion:

• Percutaneous angioplasty and stenting: Percutaneous angioplasty and stenting is a safe and effective technique for resolving symptoms and improving blood flow to the posterior circulation [10].
• Endovascular thrombectomy: Endovascular thrombectomy is a minimally invasive procedure that involves removing the clot from the affected artery using a mechanical device [3].

Surgical Options

In some cases, surgical options may be necessary for vertebral artery occlusion:

• Surgery: Surgery, including minimally invasive spine surgery, may be required to treat transient vertebrobasilar insufficiency [8].
• Vertebral artery angioplasty: Vertebral artery angioplasty can be performed with high technical and clinical success rates, low complication rates, and durable long-term results [13].

It is essential to note that the choice of treatment depends on various factors, including the severity and location of the blockage, as well as the patient's overall health. A comprehensive evaluation by a healthcare professional is necessary to determine the best course of treatment for vertebral artery occlusion.

References:

[1] Anticoagulation therapy for vertebral artery occlusion secondary to cardiogenic embolism due to atrial fibrillation or mechanical heart valves. [3] Intravenous thrombolysis (IVT) and local intra-arterial thrombolysis (IAT) for acute ischemic stroke caused by vertebral artery occlusion. [8] Surgery, including minimally invasive spine surgery, for transient vertebrobasilar insufficiency. [9] Antiplatelet agents for patients with atherosclerosis involving the vertebral arteries. [10] Percutaneous angioplasty and stenting for vertebral artery occlusion. [13] Vertebral artery angioplasty.

Vertebral artery occlusion can be challenging to diagnose, as it may present with non-specific symptoms that can mimic other conditions. However, there are several differential diagnoses that should be considered in the evaluation of vertebral artery occlusion.

Common Differential Diagnoses:

• Arterial dissection: This is a common cause of vertebral artery occlusion, particularly in younger patients [11][12].
• Atherosclerotic disease: Atherosclerosis can cause stenosis or occlusion of the vertebral artery, leading to ischemic stroke [2][3].
• Vertebral artery dissection: This is a rare but serious condition that can cause vertebral artery occlusion, particularly in patients with a known diagnosis of Turner syndrome [9].
• Cervical spine fracture evaluation: Vertebral artery injury is an important consideration in the evaluation of cervical spine fractures [11].

Other Differential Diagnoses:

• Vertebrobasilar insufficiency (VBI): This condition refers to inadequate blood flow through the posterior circulation of the brain, supplied by the vertebral arteries [10].
• Subclavian steal syndrome: This is a condition where the subclavian artery is narrowed or blocked, leading to reversed flow in the vertebral artery [13].
• Collateral artery: A collateral artery may be present in some cases of vertebral artery occlusion, which can provide alternative blood supply to the brain [13].

Key Points:

• Vertebral artery occlusion can be caused by a variety of conditions, including arterial dissection, atherosclerotic disease, and vertebral artery dissection.
• A thorough evaluation is necessary to rule out other differential diagnoses, such as cervical spine fracture or vertebrobasilar insufficiency.
• Consideration should be given to the patient's age, medical history, and symptoms when evaluating vertebral artery occlusion.

References:

[1] Context 12 [2] Context 3 [3] Context 13 [4] Context 11 [5] Context 14