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Vertebral Artery Thrombosis

Vertebral artery thrombosis is a potentially life-threatening vascular event that can occur after injury to the cervical spine, vertebral artery dissection, but also surgical intervention. When the vertebral artery is occluded, symptoms arise depending on which part of the brain is affected by ischemia. Dizziness, diplopia, Wallenberg syndrome, and even locked-in syndrome are some of the possible manifestations. Vertebral artery thrombosis must be recognized early on and imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), and CT angiography are the cornerstone for establishing the diagnosis.


Presentation

The clinical presentation of vertebral artery thrombosis significantly depends on the location of occlusion [1] [2] [3]. Wallenberg syndrome is a term denoting ischemia of the lateral medulla arising from the obstruction of the intracranial vertebral artery, manifesting as Horner's syndrome (ptosis, anhydrosis, and miosis), ataxia, dysphagia, and a reduced sensation of temperature and pain on the ipsilateral side of the face and contralateral side of the body [1]. If the middle segment of the vertebrobasilar artery (VBA) territory is affected, the most likely cause is occlusion of the basilar artery, which may, in turn, promote ischemia of the pons, quadriplegia, and anarthria with preserved consciousness, more widely known as "locked-in syndrome" [1] [2]. Coma is, in fact, a possible manifestation in the setting of iatrogenic vertebral artery thrombosis and occlusion (for example, after surgery of the cervical spine or catheterization of the internal jugular vein) [4]. However, the most common symptoms and signs of vertebral artery thrombosis are nausea, vomiting, pain in the head and neck areas, and dizziness [1] [5]. Weakness, dysarthria, and impaired mental state are also frequent findings in the setting of a vascular insult involving the vertebral arteries [1] [5].

Falling
  • Falls notwendig, können in der akuten Phase auch Gefäßdilatationen erfolgen; das Einbringen eines Stents ist möglich, muss aber aufgrund der erforderlichen Thrombozytenfunktionshemmung gut abgewogen werden. Weitere Studien, die randomisiert die i.v.[springermedizin.at]
Respiratory Distress
  • Distress Syndrome 455 Chapter 25 Critical Care Considerations Following Chest Trauma 465 Chapter 26 Respiratory Care 485 Chapter 27 Mechanical Ventilation 505 Chapter 28 Weaning from Mechanical Ventilation 525 Chapter 29 Extubation of the Difficult Airway[books.google.com]
  • The autopsy results showed acute respiratory distress and cardiovascular insufficiency.[omicsgroup.org]
Liver Dysfunction
  • Dysfunction in the Previously Well Patient 633 Chapter 36 Acute Fulminant Hepatic Failure 651 Chapter 37 The Cirrhotic Patient 667 Chapter 38 Artificial Liver and Blood Cleansing Techniques 689 Chapter 39 Acute Pancreatitis and Pancreatic Injuries 703[books.google.com]
Vascular Disease
  • You are more likely to have vascular disease as you get older.[icdlist.com]
  • Abstract Doctors Siekert, Millikan, and Whisnant, whose article appears in this issue of the A NNALS, have made many significant contributions to our understanding of the etiology and treatment of the atherosclerotic forms of cerebral vascular disease[annals.org]
  • Pathophysiology Atherosclerosis : the most common vascular disease affecting the vertebrobasilar system: [ 1 ] This affects large vessels, causing narrowing and occlusion.[patient.info]
Fracture
  • Abstract A case of thrombosis of the vertebral artery and an associated bursting fracture of the lower cervical spine is reported. Computed tomography revealed both the location and the spreading of the fractures of the injured spine.[ncbi.nlm.nih.gov]
  • CONCLUSION: The absence of neurologic symptoms in a patient with cervical spine fracture does not preclude VAT.[ncbi.nlm.nih.gov]
  • Patients with cervical spine fracture who have neurological deficits suggestive of vertebral artery injury, or those with high-risk fractures (involving the foramen transversarium) should undergo either conventional or magnetic resonance angiography.[trauma.org]
  • Results: The patient with the dislocation fracture of С6-С7 one vertebral artery was injured, with no evidence of total occlusion.[omicsgroup.org]
Osteophyte
  • The surgical exposure and control of the vertebral artery not only permit to treat lesions of the vertebral artery wall or developed in contact to it but also to improve the access to the intervertebral foramen (tumors, osteophytes), to the anterior aspect[books.google.com]
Ptosis
  • Wallenberg syndrome is a term denoting ischemia of the lateral medulla arising from the obstruction of the intracranial vertebral artery, manifesting as Horner's syndrome (ptosis, anhydrosis, and miosis), ataxia, dysphagia, and a reduced sensation of[symptoma.com]
  • Hypertension Cystic medial necrosis Respiratory tract infection Oral contraceptive use References: [1] Clinical features Non- ischemic features Ipsilateral hea dache and facial/neck pain (constant, severe, throbbing or sharp) Partial horner syndrome : ptosis[amboss.com]
  • Embolic source from heart or aorta Dissection Major Signs/Symptoms: Vertigo, nausea, vomiting Ipsilateral limb ataxia (dysmetria, dysdiadochokinesia) Gait ataxia Nystagmus Ipsilateral Horner’s syndrome due to disruption of sympathetic tract: ptosis (droopy[casemed.case.edu]
  • […] even coughing or vomiting, especially in the setting of connective tissue disease Carotid artery dissection presents as thunderclap headache or subacute headache with unilateral facial, neck or head pain with a partial Horner’s syndrome (myosis and ptosis[emergencymedicinecases.com]
  • Ipsilateral mydriasis, cranial nerve III palsy and ptosis. Contralateral hemiplegia. Benedikt's syndrome: Dorsal midbrain affected. Ipsilateral oculomotor effects as in Weber's syndrome. Contralateral tremor, ataxia or chorea.[patient.info]
Miosis
  • Wallenberg syndrome is a term denoting ischemia of the lateral medulla arising from the obstruction of the intracranial vertebral artery, manifesting as Horner's syndrome (ptosis, anhydrosis, and miosis), ataxia, dysphagia, and a reduced sensation of[symptoma.com]
  • Cystic medial necrosis Respiratory tract infection Oral contraceptive use References: [1] Clinical features Non- ischemic features Ipsilateral hea dache and facial/neck pain (constant, severe, throbbing or sharp) Partial horner syndrome : ptosis and miosis[amboss.com]
  • , and may include the following signs and symptoms: Vertigo, nausea, vomiting Ipsilateral limb ataxia (dysmetria, dysdiadochokinesia) Gait ataxia Nystagmus Ipsilateral Horner’s syndrome due to disruption of sympathetic tract: ptosis (droopy eyelid), miosis[casemed.case.edu]
Strabismus
  • […] hemiplegia/quadriplegia •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[omicsonline.org]
Vertigo
  • The classic symptoms of vertebrobasilar ischemia are dizziness , vertigo, diplopia, perioral numbness, alternating paresthesia, tinnitus , dysphasia, dysarthria, drop attacks, ataxia, and homonymous hemianopsia.[emedicine.medscape.com]
  • However, because strokes are much less common than other sources of vertigo such as ear disorders, vertigo is only caused by central nervous system problems (including stroke) about 5% of the time. Migraine is a common cause of vascular vertigo.[dizziness-and-balance.com]
  • Symptoms of Vertebral Artery Stenosis A vertebrobasilar stroke classically causes vertigo, ataxia and loss of balance. Various cranial nerves can be dysfunctional. Breathing and consciousness may be impaired.[angiologist.com]
  • Symptoms reported with vertebrobasilar strokes include: Vertigo - common - and this may be the only symptom. Nausea and vomiting. Disturbance of consciousness. Headache.[patient.info]
  • This syndrome is known as the Wallenberg or “ lateral medullary ” syndrome, and may include the following signs and symptoms: Vertigo, nausea, vomiting Ipsilateral limb ataxia (dysmetria, dysdiadochokinesia) Gait ataxia Nystagmus Ipsilateral Horner’s[casemed.case.edu]
Dizziness
  • Dizziness, diplopia, Wallenberg syndrome, and even locked-in syndrome are some of the possible manifestations.[symptoma.com]
  • The classic symptoms of vertebrobasilar ischemia are dizziness , vertigo, diplopia, perioral numbness, alternating paresthesia, tinnitus , dysphasia, dysarthria, drop attacks, ataxia, and homonymous hemianopsia.[emedicine.medscape.com]
  • A neurosurgical consult was warranted, the patient recived treatment with steroids and cervical collar and finally nine days later was discharged without dizziness or headache.[trauma.org]
  • This results in dizziness, nausea, syncope, dysarthria, dysphagia, and disturbances of the hearing or vision, paresis or paralysis of patients with VBI [4]. Clinically Relevant Anatomy The vertebral artery is a major artery in the neck [6].[physio-pedia.com]
  • No dizziness. Wednesday Went to get a haircut and noticed that the pain when the comb touched my scalp was pretty impressive. Also wearing a baseball cap was very painful (yes, I know, over 30 shouldn’t wear baseball caps!).[blog.thesullivangroup.com]
Quadriplegia
  • If the middle segment of the vertebrobasilar artery (VBA) territory is affected, the most likely cause is occlusion of the basilar artery, which may, in turn, promote ischemia of the pons, quadriplegia, and anarthria with preserved consciousness, more[symptoma.com]
  • Basilar Artery Thrombosis and stenosis: As the basilar artery supplies most of the brainstem, occlusion is commonly catastrophic resulting in quadriplegia. Death from respiratory failure is common.[dizziness-and-balance.com]
  • […] visually guide a hand to its target); gaze apraxia (inability to focus on a desired target) Proximal PCA Infarction: If the very proximal PCA is infarcted, the small perforators to the thalamus and cerebral peduncle may be affected, resulting in hemi- or quadriplegia[casemed.case.edu]
  • Usually dramatic and sudden, causing quadriplegia with preserved consciousness. Internuclear ophthalmoplegia: Horizontal gaze palsy. In younger patients it may be caused by multiple sclerosis.[patient.info]
  • •Decreased level of consciousness/coma •Hemiparesis /quadriparesis, hemiplegia/quadriplegia •Hypaesthesia or anaesthesia •Cerebellar signs •Vertigo,nausea, vomiting, directional nystagmus •Disturbance of respiration, blood pressure and heart rate •Headache[omicsonline.org]
Drop Attacks
  • The classic symptoms of vertebrobasilar ischemia are dizziness , vertigo, diplopia, perioral numbness, alternating paresthesia, tinnitus , dysphasia, dysarthria, drop attacks, ataxia, and homonymous hemianopsia.[emedicine.medscape.com]
  • Positive symptoms include (The 5 D’s) dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea and vomiting, sensory changes, nystagmus, etc. [10] Below is an alternate vertebral artery test, that may be used in certain settings.[physio-pedia.com]
  • Contralateral motor weakness (may cause a 'drop attack'). Sensory disturbance affecting pain and temperature. Incontinence. There may be a history of associated risk factors.[patient.info]
Altered Mental Status
  • , and hypertensive encephalopathy (altered mental status with papilledema and end‐organ damage in the setting of severe hypertension) 10 serious causes of headache to consider for every ED patient with headache Lesion on CT scan (blood, pus or tumor):[emergencymedicinecases.com]
  • ., papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation); HIV-positive patients with a new type of headache; immunocompromised patient with unexplained headache[blog.thesullivangroup.com]

Workup

Because of the life-threatening nature of the disorder, vertebral artery thrombosis must be recognized as soon as possible. The first and most important components of the workup are a properly obtained patient history (during which the exact onset of symptoms, the circumstances that preceded their appearance, and their progression must be revealed) and a thorough physical examination that confirms neurological deficits caused by ischemia. Clinical findings should be strong enough to raise a suspicion toward an ongoing process related to the vertebral arteries, which is particularly supported if prior trauma or surgical/diagnostic procedure involving the cervical area have happened. Still, the diagnosis is confirmed through the employment of various imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), MR or CT angiography (MRA and CTA, respectively) [3] [6] [7] [8] [9]. Digital subtraction angiography (DSA), although being the most reliable study, is very risky due to its invasiveness. Moreover, there is the potential need for general anesthesia [1]. If thromboembolus is suspected to have originated from the heart, cardiac ultrasonography should be performed [1].

Treatment

  • […] vertebral artery stenting Abstract PDF Hassan A, ul Haq T, Khimani F, Ali S, Dhakam S, Syed NA Correspondence: Dr Nadir Ali Syed, [email protected] ABSTRACT Acute vertebrobasilar artery occlusion is a life-threatening event, even after thrombolytic treatment[smj.org.sg]
  • Numerous medical conditions may cause or mimic vertebrobasilar ischemia, thus confounding the selection of patients in need of posterior circulation treatment.[emedicine.medscape.com]
  • Treatment The main objective in treatment of the acute ischemic stroke is the restoration of cerebral blood flow.[omicsonline.org]
  • References: [1] [2] Treatment Treatment should be initiated after an intracerebral hemorrhage has been ruled out Heparin therapy followed by oral anticoagulation for 3–6 months and/or Antiplatelet agents for 1 year Possibly angioplasty / stenting or surgical[amboss.com]
  • Conclusion Ultimately, the best treatment of these iatrogenic injuries should start with prevention.[casereports.in]

Prognosis

  • Prognosis of Patients with spontaneous Vertebral Artery dissection is good & 90% are expected to make an excellent recovery. Those associated with SAH have guarded prognosis.[vertebralarterydissection.com]
  • Long term prognosis is not encouraging with residual disabilities being the norm.[jneuro.com]
  • […] of complications Risk of stroke greatest in the first 24 hours after cervical artery dissection and decreases over the next 7 days relatively low after 2 weeks Extracranial dissection has more favourable prognosis than intrcranial dissection Spontaneous[lifeinthefastlane.com]
  • Even when there are no symptoms, vertebral artery stenosis denotes poor prognosis.[angiologist.com]
  • Incidence and prognosis of 50% symptomatic vertebral or basilar artery stenosis: prospective population-based study . Brain . 2009 ; 132 : 982 – 988 . 6.[cambridge.org]

Etiology

  • Abstract Doctors Siekert, Millikan, and Whisnant, whose article appears in this issue of the A NNALS, have made many significant contributions to our understanding of the etiology and treatment of the atherosclerotic forms of cerebral vascular disease[annals.org]
  • It is important to contrast these clinical manifestations with those involving strokes of the anterior circulation, as the etiology and treatment may differ.[casemed.case.edu]
  • Etiology Frequently caused by penetrating or blunt trauma (e.g., high impact car accidents) but up to 40% of cases result from mild trauma (e.g., minor sports injuries ) or other mechanical triggering events (e.g., coughing, sneezing, chiropractic maneuvers[amboss.com]
  • […] internal carotid artery is most commonly affected vertebral artery dissections are uncommon Carotid and vertebral artery dissections can occur intracranially and extracranially; the former is rarer and more serious They may be spontaneous or traumatic in etiology[lifeinthefastlane.com]
  • This case report describes the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.[casereports.in]

Epidemiology

  • […] artery ( 4:1 ) References: [1] [2] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Archives of neuroscience. 2(4):. 2015. [ pubmed ] [ free full text ] Thanvi B, Munshi SK, Dawson SL, Robinson TG.[lifeinthefastlane.com]
  • Epidemiology A relatively uncommon form of stroke.[patient.info]
  • Epidemiology and risk factors Basilar artery is the artery most often affected with atherosclerosis of all the intracranial arteries [ 1 ].[omicsonline.org]
Sex distribution
Age distribution

Pathophysiology

  • Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Archives of neuroscience. 2(4):. 2015. [ pubmed ] [ free full text ] Thanvi B, Munshi SK, Dawson SL, Robinson TG.[lifeinthefastlane.com]
  • Pathophysiology Atherosclerosis : the most common vascular disease affecting the vertebrobasilar system: [ 1 ] This affects large vessels, causing narrowing and occlusion.[patient.info]
  • In Barnet HJM (and others, Eds), Stroke: Pathophysiology, Diagnosis and Management. New York: Chrchill-Livingstone, pp 549-619, 1986 Dai, A. I. and M. Wasay (2006). "Wernekink comissure syndrome: a rare midbrain syndrome secondary to stroke."[dizziness-and-balance.com]

Prevention

  • Discuss strategies and medications with your doctor to help prevent VBI or lessen its symptoms.[healthline.com]
  • […] s" were thought to follow thrombosis of small intracranial arteries, so that the physician directed his therapy at the prevention of the complications of bed rest and not at the primary cerebral-vascular problem.[annals.org]
  • Even with vertebral artery occlusion, collaterals (circle of Willis) may prevent ischaemia.[patient.info]
  • The preventive or curative endovascular treatment of embolism to the distal vascular network must be achieved at the same time as the treatment of the primary lesion. Vertebro-basilar strokes can be prevented by two different techniques.[em-consulte.com]
  • The aim of treatment is to prevent neurological deficit. The mechanism of ischaemia after dissection probably results from distal microemboli.[vertebralarterydissection.com]

References

Article

  1. Schoen JC, Boysen MM, Warren CR, Chakravarthy B, Lotfipour S. Vertebrobasilar Artery Occlusion. West J Emerg Med. 2011;12(2):233-239.
  2. Caplan LR, Chung C-S, Wityk RJ, et al. New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes. J Clin Neurol. 2005;1:14–30.
  3. Torina PJ, Flanders AE, Carrino JA, et al. Incidence of vertebral artery thrombosis in cervical spine trauma: correlation with severity of spinal cord injury. AJNR Am J Neuroradiol. 2005;26(10):2645-2651.
  4. Van Vrancken MJ, Guileyardo J. Vertebral artery thrombosis and subsequent stroke following attempted internal jugular central venous catheterization. Proc (Bayl Univ Med Cent). 2012;25(3):240-242.
  5. Gul HL, Lau SYM, Chan-Lam D, Ng J-P. Vertebral artery thrombosis: a rare presentation of primary polycythaemia. BMJ Case Rep. 2014;2014:bcr2013201347.
  6. Brandt T, Knauth M, Wildermuth S, et al. CT antiography and Doppler sonography for emergency assessment in acute basilar artery ischemia. Stroke. 1999;30:606–612.
  7. Shi S, Chen K, Ge X, Ni B. Lessons from the Diagnosis and Treatment of Spontaneous Vertebral Arterial Dissection: Case Report. Interv Neuroradiol. 2009;15(2):203-208.
  8. Yang CW, Carr JC, Futterer SF, et al. Contrast-enhanced MR angiography of the carotid and vertebrobasilar circulations. Am J Neuroradiol. 2005;26:2095–2101.
  9. Chen CJ, Tseng YC, Lee TH, et al. Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. Am J Neuroradiol. 2004;25:769–774.

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Last updated: 2018-06-21 20:38