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| {{SI}} | | {{Vertebrobasilar insufficiency}} |
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| '''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 |
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| == 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.
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| ==Historical Perspective== | | ==[[Vertebrobasilar insufficiency historical perspective|Historical Perspective]]== |
| The syndrome of vertebrobasilar insufficiency was first described no later than 1969 by German docters Pfaltz CR, Richter HR.<ref name="pmid5355581">Pfaltz CR, Richter HR (1969) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=5355581 [Syndrome of vertebrobasilar insufficiency. Etiology and pathogenesis of the cochleovestibular symptoms in cerebral circulation disorders].] ''Arch Klin Exp Ohren Nasen Kehlkopfheilkd'' 193 (2):190-200. PMID: [http://pubmed.gov/5355581 5355581]</ref>The first surgical treatment was first suggested in 1971 to remedy the vertebrobasilar insufficiency caused by cervical spondylosis<ref name="pmid5096552">Smith DR, Vanderark GD, Kempe LG (1971) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=5096552 Cervical spondylosis causing vertebrobasilar insufficiency: a surgical treatment.] ''J Neurol Neurosurg Psychiatry'' 34 (4):388-92. PMID: [http://pubmed.gov/5096552 5096552]</ref>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?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>A 3-steps approach to diagnosis the VBI was put forward in 1979.<ref name="pmid496201">Valvassori G, Dobben GD (1979) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=496201 Vertebrobasilar insufficiency.] ''Ann Otol Rhinol Laryngol'' 88 (5 Pt 1):689-92. PMID: [http://pubmed.gov/496201 496201]</ref>In the following 20 years,different kinds of surgery was rapidly developed to treat the VBI,such as microsurgey,fenestration,passby surgery,angioplasty.
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| ==Classification== | | ==[[Vertebrobasilar insufficiency classification|Classification]]== |
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| ==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.
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| ==Causes== | | ==[[Vertebrobasilar insufficiency causes|Causes]]== |
| ===Life Threatening Causes===
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| ===Common Causes=== | | ==[[Vertebrobasilar insufficiency differential diagnosis|Differentiating Vertebrobasilar insufficiency from other Diseases]]== |
| The most common causes of posterior circulation
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| ischaemia are cardioembolism, large artery athero-
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| sclerosis, 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>
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| ===Causes by Organ System=== | | ==[[Vertebrobasilar insufficiency epidemiology and demographics|Epidemiology and Demographics]]== |
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| {|style="width:80%; height:100px" border="1"
| | ==[[Vertebrobasilar insufficiency risk factors|Risk Factors]]== |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[ Intracranial atherosclerosis ]], [[ vertebral artery dissections ]],[[maldevelopment or absent of unilateral vertebral artery]],[[arterial embolism ]]
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| [[physiatric cervical manipulation ]]
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| [[Cervical spondylosis ]],[[degenerative cervical spine changes ]],[[cervical compressive lesions ]],[[Cervical tuberculosis]],[[Cervical injury]],[[osteoporosis]]
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| [[Cervical injury]]
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Dental'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[ Postural changes,like head rotation or extension ]]
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| |}
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| ===Causes in Alphabetical Order=== | | ==[[Vertebrobasilar insufficiency natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| arterial embolism
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| cervical compressive lesions
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| Cervical injury
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| Cervical spondylosis
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| Cervical tuberculosis
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| degenerative cervical spine changes
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| Intracranial atherosclerosis
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| maldevelopment or absent of unilateral vertebral artery
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| osteoporosis
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| Postural changes
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| vertebral artery dissections
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| ==Differentiating Vertebral Artery Disease from other Diseases==
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| It's wery hard to make differentia diagnosis between the high-risk posterior circulation ischaemic
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| events and carotid artery events before brain imaging.
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| ==Epidemiology and Demographics==
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| 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>
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| ==Risk Factors==
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| The risk factors of VBI is similar to arteriosclerosis:
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| ==Screening==
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| ==Natural History, Complications and Prognosis==
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| ===Complications===
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| 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.
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| ==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]] |
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| 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
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| 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.
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| ===Symptoms===
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| [[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. | |
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| 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.
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| 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>
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| 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>
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| ===Physical Examination===
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| ===Laboratory Finding===
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| ====CT====
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| ====MRI====
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| ==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]] |
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| 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]] |
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| 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.
| | {{WikiDoc Help Menu}} |
| | | {{WikiDoc Sources}} |
| 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.
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| 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>.
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| ===Pharmacotherapy===
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| For patients with acute ischemic syndromes that
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| involve the vertebral artery territory and angiographic
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| evidence of thrombus in the extracranial portion of the
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| vertebral artery, anticoagulation is generally recom-
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| mended for at least 3 months, whether or not thrombo-
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| 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-
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| farin versus Aspirin for Symptomatic Intracranial Dis-
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| ease) trial found aspirin and warfarin to be equally
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| efficacious after initial noncardioembolic ischemic
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| 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>
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| Ticlopidine was superior to aspirin for
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| secondary prevention of ischemic events in patients
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| 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>
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| ===Surgery and Device Based Therapy===
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| ====Indications for Surgery====
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| ==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>==
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| ===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>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | 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>
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| | 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>
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| | 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>
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |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>
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| |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>
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| |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>
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| |}
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| ===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>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | 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>
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| | 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>
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| | 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>
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| |}
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |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>
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| |}
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| ==References==
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| {{Reflist|2}}
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| {{WH}} | |
| {{WS}} | |
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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]]
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| [[Category:Disease]]
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