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Basilar Artery Occlusion

Occlusion and Stenosis of Basilar Artery

Basilar artery occlusion is a life-threatening vascular pathology that can initially present with relatively mild and nonspecific symptoms. Eventually, quadriparesis, dysarthria, altered level of consciousness, and ocular abnormalities may ensue and put the patient at great risk. A presumptive diagnosis can be made during the clinical assessment, but imaging studies are needed in order to confirm that the basilar artery is the site of the occlusion. Catheter angiography and either computed tomography (CT) angiography or magnetic resonance (MR) angiography are recommended modalities.


Presentation

Signs and symptoms of basilar artery occlusion vary depending on the extent (but also the site) of the occlusion. Unlike the majority of cerebrovascular insults, the clinical course is frequently gradual and starts with relatively mild and nonspecific complaints such as a headache and possibly vertigo, which mimics a transient ischemic attack (TIA) and delays the diagnosis [1] [2] [3]. Eventually, the typical signs of basilar artery occlusion appear - altered mental state (patients are often in a coma), hemiparesis or quadriparesis, dysphagia, dysarthria, and other neurological deficits [1] [2] [3] [4]. Additional findings that could be encountered are nausea, vomiting, bulbar dysfunction, locked-in syndrome, ataxia, deficits of the extraocular muscles, and nystagmus, as well as the hearing loss [1] [2] [3] [4]. Epileptic-like events characterized by bilateral twitching or shaking may be present [2]. Specific symptoms appear in relation to the site of occlusion [5]. For example, occlusion of the middle segment of the basilar artery (which supplies the lateral and medial pons) can result in ipsilateral loss of sensation of the face, dysmetria, and contralateral hemiparesis [5]. Studies that have investigated basilar artery occlusion in both children and adults show a marked predominance of male gender [3] [4].

Raynaud Phenomenon
  • Abstract A previously healthy 22-year-old man presented with thoracic outlet syndrome manifesting as Raynaud's phenomenon in the left hand and embolic occlusion of the basilar artery.[ncbi.nlm.nih.gov]
Coarctation of the Aorta
  • Abstract We report a case of an 8-year-old girl with posterior fossa abnormalities, haemangioma, arterial lesions, cardiac abnormalities or coarctation of the aorta and eye abnormalities syndrome with right carotid aplasia and complete basilar occlusion[ncbi.nlm.nih.gov]
Hyperthermia
  • Her hyperthermia did not respond to any antipyretic treatments. A water-cooling blanket was utilized to control her hyperthermia; however, body temperatures fluctuated at a range of 35.5-40.0 degrees C.[ncbi.nlm.nih.gov]
Refractory Shock
  • Despite aggressive surgery, sepsis persisted, and therapy was limited by uncontrollable coagulopathy and catecholamine refractory shock after 15 days.[ncbi.nlm.nih.gov]
Flushing
  • Heparin was only applied for catheter flushing (500 IU/h). The patient with the atherothrombotic occlusion was treated with additional percutaneous transluminal angioplasty and stenting.[ncbi.nlm.nih.gov]
Tinnitus
  • Hypaesthesia or anaesthesia •Cerebellar signs •Vertigo,nausea, vomiting, directional nystagmus •Disturbance of respiration, blood pressure and heart rate •Headache, •Incontinence •Oculomotor signs •Facial palsy •Double vision, strabismus, skew deviation •Tinnitus[omicsonline.org]
  • Major neurological symptoms include deafness on the affected side, the weakness of facial muscles, dizziness true (system), nausea and vomiting, nystagmus, tinnitus, and cerebellar ataxia, Horner's syndrome, paresis of horizontal gaze.[minclinic.ru]
Claustrophobia
  • Claustrophobia is another important adverse factor when using MRI as an imaging study.[symptoma.com]

Workup

Because of the insidious onset of symptoms, the physician must suspect basilar artery occlusion if any of the abovementioned manifestations are observed. Cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, or prior vascular insults are present in a number of patients [3], meaning that a fully obtained patient history can be of great help in raising clinical suspicion. The neurological exam, however, is the crucial component of the workup, as a detailed assessment of cranial nerve and brainstem functions might reveal the exact site of the lesion [2]. To make a definite diagnosis, imaging studies need to be employed. Computed tomography (CT) is usually the first-line study in patients who exhibit stroke-like symptoms, but the location of the basilar artery is a significant barrier for adequate CT imaging [5]. On the other hand, magnetic resonance imaging (MRI) is a more suitable study that can delineate the soft tissues in more details, particularly through diffusion-weighted imaging (DWI). Importantly, the procedure is time-consuming and is contraindicated for patients with pacemakers or foreign bodies made of metal [5]. Claustrophobia is another important adverse factor when using MRI as an imaging study [5]. Studies recommend conventional catheter cerebral angiography, and either CT and MR angiography, as these procedures provide a precise view of the desired blood vessels [5] [6]. MR angiography with contrast is particularly useful for evaluation of vertebrobasilar vessels [6].

Seizure Activity
  • We report a case of an acute basilar artery occlusion presenting with decreased level of consciousness associated with rhythmic tonic movements of the four extremities, mimicking seizure activity.[ncbi.nlm.nih.gov]

Treatment

  • The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings.[ncbi.nlm.nih.gov]
  • Subgroup analysis on the treatment window revealed that onset-to-treatment time of 12 hours.[ncbi.nlm.nih.gov]
  • Although early arterial recanalization by thrombolytic agent has became the new trend of treatment, for some neurologists anticoagulant is still a conventional alternative treatment of basilar artery occlusion, especially in longer-existing ischemic deficits[ncbi.nlm.nih.gov]
  • KEYWORDS: Thrombectomy; basilar artery; endovascular treatment; randomized; stroke[ncbi.nlm.nih.gov]
  • Status of dominant VA and various treatment strategy should be considered when performing endovascular treatment for recanalization in patients with symptomatic BAO. Copyright 2017 Elsevier Masson SAS. All rights reserved.[ncbi.nlm.nih.gov]

Prognosis

  • DWI, posterior circulation Acute Stroke Prognosis Early CT Score of 7 (versus CONCLUSIONS: This study suggested that initial infarction severity and posterior circulation Acute Stroke Prognosis Early CT Score on a pretreatment DWI are independent predictors[ncbi.nlm.nih.gov]
  • Abstract Basilar artery occlusion is usually associated with a poor prognosis. Nevertheless, intra-arterial thrombolysis has been shown to improve clinical outcome in selected cases.[ncbi.nlm.nih.gov]
  • Abstract Basilar artery occlusions are rare but have a very poor prognosis. Intra-arterial thrombolysis may produce recanalization and better clinical outcome.[ncbi.nlm.nih.gov]
  • Wider use of these combined diagnostic methods will allow the detection of less severe basilar artery dissection, thus extending the spectrum of presentation and prognosis.[ncbi.nlm.nih.gov]
  • Abstract Hyperthermia, not uncommon in severe brainstem stroke, is frequently difficult to control and associated with a poor prognosis and high mortality.[ncbi.nlm.nih.gov]

Etiology

  • In the cases of pure basilar artery occlusion, the most common causes were trauma and arteritis, but in most such cases, the etiology could not be determined.[ncbi.nlm.nih.gov]
  • An etiology of vascular dissection may account for the early postprocedural recurrence.[ncbi.nlm.nih.gov]
  • A detailed etiological evaluation revealed no risk factor for ischemic stroke. We believe that the migraine-like headache was the first symptom of cerebral ischemia and that sumatriptan accelerated the development of the infarction.[ncbi.nlm.nih.gov]
  • In both the cases, extensive diagnostic work-up did not reveal the etiology.[thieme-connect.com]
  • Cerebrovascular accidents (CVAs) are one of the most serious etiologies for altered mental status.[westjem.com]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology and risk factors Basilar artery is the artery most often affected with atherosclerosis of all the intracranial arteries [ 1 ].[omicsonline.org]
  • Randomized control trials need to be performed. [1] Epidemiology [ edit ] The incidence of VBI increases with age and typically occurs in the seventh or eighth decade of life. [ citation needed ] Reflecting atherosclerosis , which is the most common cause[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Because cerebral vessel occlusions after burn injuries are reported rarely, the current literature was reviewed, and possible pathophysiological aspects are discussed.[ncbi.nlm.nih.gov]
  • Pathophysiology of ischemic stroke in the anterior inferior cerebellar artery basin Occlusion (blockage) inferior cerebellar artery front leads to the development of cerebral infarction of varying severity, because the size of this artery and its territory[minclinic.ru]

Prevention

  • Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children.[ncbi.nlm.nih.gov]
  • Immediate application of intravenous ethanol and hemodialysis could not prevent the development of a malignant brain edema within hours.[ncbi.nlm.nih.gov]
  • Treatment with methylprednisolone and MMF in addition to dual antiplatelet therapy has thus far prevented further relapses and was associated with a satisfactory neurological outcome.[thieme-connect.com]
  • Página 310 - A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. ‎[books.google.es]

References

Article

  1. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011;10(11):1002-1014.
  2. Demel SL, Broderick JP. Basilar Occlusion Syndromes: An Update. Demaerschalk BM, ed. Neurohospitalist. 2015;5(3):142-150.
  3. Israeli-Korn SD, Schwammenthal Y, Yonash-Kimchi T, et al. Ischemic stroke due to acute basilar artery occlusion: proportion and outcomes. Isr Med Assoc J. 2010;12(11):671-675.
  4. Goeggel Simonetti B, Ritter B, Gautschi M, et al. Basilar artery stroke in childhood. Dev Med Child Neurol. 2013;55(1):65-70.
  5. Nouh A, Remke J, Ruland S. Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management. Front Neurol. 2014;5:30.
  6. Khan S, Rich P, Clifton A, Markus HS. Noninvasive detection of vertebral artery stenosis a comparison of contrast-enhanced MR angiography, CT angiography, and ultrasound. Stroke. 2009;40(11):3499–3503.

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Last updated: 2018-06-21 22:22