Overview: Vertebral artery stenosis can cause posterior cerebral ischemia.
Narrowing of the lumen of the vertebral artery can cause posterior cerebral ischemia, which may be asymptomatic or manifested by vertigo, double vision, ambiguous pronunciation, dysphagia, and paralysis of the limbs, etc. Often originating from atherosclerosis, vasculitis, and congenital malformations of the vessels, etc., with pharmacological and interventional treatments as the mainstay.
Definition
Vertebral artery stenosis refers to the narrowing of the lumen of the vertebral artery in one or more places.
The bilateral vertebral arteries enter the skull and converge to form the basilar artery, which is the main source of blood supply for the brainstem, cerebellum, medulla oblongata and other posterior circulatory systems.
Vertebral artery wall thickening, lumen narrowing, tortuosity, or spasm can lead to chronic cerebral ischemia in the posterior circulatory system.
Plaque or thrombus dislodgement at the vertebral artery stenosis can cause distal vascular occlusion, leading to transient ischemic attack (TIA) or cerebral infarction in the posterior circulatory system.
Classification
Classification is usually based on the degree of stenosis.
Mild stenosis: The lumen is <50% narrowed.
Moderate stenosis: 50% to 69% lumen narrowing.
Severe stenosis: 70% to 99% narrowing of the lumen.
Occlusion: no blood flow through the lumen.
Morbidity
There are 18 new acute posterior ischemic strokes per 100,000 people each year.
The incidence of acute posterior circulation ischemic stroke is high, accounting for approximately 20% to 25% of all ischemic strokes.
Approximately 20% of posterior circulation strokes are caused by vertebral artery stenosis.
Causes
Causes
The following factors are strongly associated with the development of vertebral artery stenosis.
Atherosclerosis
Atherosclerosis is the most common cause of stenosis in vertebral arteries due to the deposition of lipids in the inner wall of the arteries as a result of abnormal lipid metabolism, resulting in the formation of plaques and narrowing of the arteries.
Atherosclerotic lesions may also lead to disruption of the wall structure and the development of entrapments or hematomas in the arteries, resulting in vascular occlusion or stenosis.
Vasculitis
Various causes of vascular inflammatory response, resulting in the destruction of the structure of the arterial wall, hardening, thickening, resulting in lumen narrowing and occlusion.
Other causes
Vascular congenital malformation, external force, trauma, radiation injury, foreign body embolism and other causes of hemodynamic changes can also cause stenosis of the vertebral artery.
Risk factors
People with any of the following risk factors are at high risk for the disease.
Middle-aged or elderly people.
Hypertension, diabetes mellitus, abnormal lipid metabolism, overweight, obesity.
Suffering from stroke, atherosclerosis in other parts of the body, or coronary atherosclerotic heart disease.
Having someone in the family with cerebrovascular disease (family history of cerebrovascular disease).
Bad life habits, such as long-term smoking, drinking, lack of exercise, high salt and high fat diet.
History of infections such as cytomegalovirus, streptococcus, or history of aortitis.
Pathogenesis
The clinical symptoms of vertebral artery stenosis depend on the effect on the blood supply to the posterior circulatory system. This is related not only to the degree of stenosis of the vertebral artery vessels, but also to the compensation of collateral circulation.
If the effect on the blood supply to the posterior circulatory system is slight, there are no obvious symptoms.
Persistent insufficiency of blood supply is manifested by symptoms of chronic posterior circulation ischemia.
When transient, reversible ischemia of the vertebral arteries due to blood flow, microemboli, and vasospasm occurs, it results in a transient ischemic attack of the posterior circulatory system, also known as a vertebrobasilar system TIA.
Acute and severe ischemia manifests as acute posterior circulation ischemic stroke.
Symptoms
Chronic posterior circulation ischemia
Headache.
Vertigo: sensation of heavenly rotation, rotation of self and objects, unsteadiness.
Nausea, vomiting.
Ataxia: uncontrolled movement of limbs, inability to hold things, or inability to walk in a straight line, unsteady standing and gait.
Dysarthria: slurred articulation, slow and prolonged syllables, unequal voice strength, and incoherent speech.
Dysphagia: Difficulty in drinking and swallowing food, inability to swallow.
Limb weakness: difficulty in lifting upper limbs, unable to hold things; unable to stand or walk.
Visual impairment: seeing double images, seeing one as two (diplopia); vision loss.
Sensory abnormalities: numbness around the mouth, decreased sensitivity of the limbs to pain or hot and cold stimuli, and also numbness.
Cognitive deficits: quick forgetting of things that have happened, inability to do simple calculations, getting lost in familiar places.
TIA of the vertebrobasilar system
Sudden vertigo, nausea, vomiting, falling when turning or tilting the head, short-term memory loss.
The above symptoms usually do not last more than 1 hour, and the longest time is not more than 24 hours will be relieved by themselves, without sequelae, but can be repeated episodes.
Acute posterior circulation ischemic stroke
Persistent and severe symptoms such as vertigo, ataxia, quadriplegia, coma, high fever, etc. The condition is critical and can lead to death.
Continuous progression for more than 24 hours, not relieved on its own.
Consultation
Department of Medicine
Emergency Department
For symptoms such as severe headache, dizziness, double vision, visual disturbances, limb movement disorders, dysarthria/phagia, or even paralysis and coma, it is recommended to go to the Emergency Department as soon as possible.
Neurology, Neurosurgery, Interventional Medicine, Vascular Surgery
If vertebral artery stenosis is detected during a physical examination, or symptoms such as vertigo, syncope, blurred vision, diplopia, etc. are present, it is recommended that you seek medical attention from the Department of Neurology, Department of Neurosurgery, Department of Interventional Medicine, or Department of Vascular Surgery.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for medical treatment
Before seeking medical treatment, it is recommended to rest in bed and minimize movement and activities.
Try to keep a record of symptoms, duration, etc. for your doctor’s reference.
If you have the habit of monitoring and recording your blood pressure and blood sugar every day, you can provide the records to the doctor.
Preparation Checklist for Doctor’s Visit
Symptom list
In particular, you should pay attention to the time of the earliest occurrence of the symptoms, special manifestations, etc.
Are there any headaches, dizziness, nausea or vomiting?
Is there any weakness, numbness, or unsteady gait in the limbs?
Choking on water, slurred speech, etc.?
Any double vision, loss of vision?
When did the symptoms first appear and approximately how long did they last each time?
Any aggravating or relieving factors?
Medical History Checklist
Is there any family history of cerebrovascular disease?
Is there chronic smoking, alcohol consumption, lack of exercise, high salt and high fat diet, obesity?
Is there a history of infections such as cytomegalovirus, streptococcus, or a history of aortitis?
Are there any diseases such as hypertension, hyperlipidemia, diabetes mellitus?
Any disease such as stroke, atherosclerosis in other parts of the body, coronary atherosclerotic heart disease, etc.?
Any history of infections such as cytomegalovirus, streptococcus, tuberculosis, etc. or a history of aortitis?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Imaging: cranial CT, MRI, cerebral angiography
Ultrasonography: transcranial Doppler, carotid ultrasonography, etc.
Laboratory tests: blood glucose, blood lipids, coagulation function, markers of myocardial injury, etc.
Medication list
Medications used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office
Antiplatelet aggregation drugs: aspirin, clopidogrel, etc.
Lipid-lowering drugs: atorvastatin, fenofibrate, resuvastatin, etc.
Antihypertensive drugs: nifedipine, captopril, chlorosartan, irbesartan, etc.
Hypoglycemic drugs: glibenclamide, metformin, acarbose, insulin, etc.
Diagnosis
Diagnosis is based on
Medical history
Middle-aged or older adults.
Family history of the disease.
Long-term smoking, alcohol consumption, lack of exercise, high salt and high fat diet, obesity.
Suffering from hypertension, hyperlipidemia, diabetes mellitus and other diseases.
Suffering from stroke, atherosclerosis in other parts of the body, coronary atherosclerotic heart disease and other diseases.
Have a history of infection such as cytomegalovirus, streptococcus, or a history of aortitis.
Clinical manifestations
Symptoms
May be asymptomatic or present with headache, vertigo, diplopia, visual disturbances, dysphagia/ dysarthria, limb paralysis, coma.
Physical Signs
Physicians use physical examination to learn about muscle tone, muscle strength, skin sensation, cranial nerve function, nerve reflexes, and ataxia.
Muscle tone: To find out which parts of the body have changes in muscle tone by feeling the resistance when the patient’s joints are passively flexed and extended by hand.
Muscle strength check: Observe whether the patient can complete movements such as lifting hands, sitting up, standing, walking, etc. and whether assistance is needed.
Skin sensory examination: Slide a cotton swab over the patient’s skin or use a blunt needle to gently prick the skin to assess the degree of sensory impairment according to the sensitivity to sensation.
Cranial nerve function check: Cooperate with the doctor to complete a series of movements and tests such as eye movement, opening and closing the eyes, puffing up the cheeks, swallowing, etc. to determine whether the cranial nerve function is impaired.
Swallowing function test: Observe whether there is choking when drinking water to assess the swallowing function.
Nerve reflex examination: Observe the contraction of forearm and thigh muscles when knocking the tendons of elbow and knee to assess whether the nerve reflex is abnormal.
Ataxia examination: Observe the accuracy and speed with which the patient accomplishes specific movements to assess whether ataxia exists. For example, the patient uses the pointer finger to point toward the doctor’s fingertips and the tip of his or her nose, or slides the heel of one side of the foot from the knee along the anterior aspect of the calf in the supine position to the foot.
Laboratory tests
Biochemical examination
Main items: blood glucose, blood lipids, etc.
Purpose of examination: To detect the presence of high-risk factors, assess the overall physical condition and help determine the treatment plan.
Common results: elevated blood glucose, blood lipids, etc. can be detected.
Precautions: Fasting is required, and some items need to be checked regularly in order to monitor the body’s condition and assess the effectiveness of treatment.
Inflammation-related indicators
Main items: erythrocyte sedimentation rate, C-reactive protein, etc.
Purpose of examination: To detect the presence of inflammatory reaction.
Common findings: Erythrocyte sedimentation rate and C-reactive protein may be elevated in aortitis. In addition, the routine blood test in the active stage of aortitis can also see an increase in white blood cells or platelets.
Imaging
Ultrasound of blood vessels in the neck
Ultrasound of the blood vessels in the neck is the preferred screening method for this disease, as it allows observation of parameters such as lumen, wall, and blood flow velocity.
The vertebral arteries are small and distributed in multiple segments. Ultrasound is easy to detect stenosis in the transverse foraminal segment of the vertebral arteries, while stenosis above the transverse foraminal segment is relatively difficult to visualize, and needs to be combined with other examination methods.
Ultrasound is economical, convenient, noninvasive, and repeatable, but the results are highly dependent on the experience of the operator.
Cranial magnetic resonance imaging (MRI)
It can detect ischemia and infarction in the whole brain, including the area supplied by the vertebral artery.
It is particularly indicated when acute cerebral infarction is suspected and can show the area of the lesion several hours after the onset of the disease.
Cautions: Cannot be used to observe blood vessels and blood flow; people with dentures, cardiac stents and other metal implants in the body need to inform the radiologist to decide whether MRI can be performed according to the specific magnetic resonance machine.
Head and Neck Magnetic Resonance Imaging (MRA)
It shows the vertebral artery more clearly, can dynamically display the direction of blood flow, and is more intuitive for the display of collateral circulation.
It can be used in conjunction with parenchymal MRI to more sensitively detect small infarcts in the posterior circulation.
MRA results may magnify the degree of stenosis in the vertebral arteries, and stent restenosis cannot be determined.
Precautions are similar to those for conventional MRI.
Head and neck computed tomography angiography (CTA)
CTA can show the size, shape, blood flow, wall and other characteristics of the vessel lumen, and can observe the site and degree of stenosis in multiple directions and angles.
CTA can also clearly observe the relationship between blood vessels and surrounding tissues.
Cautions: CTA has a certain degree of radioactivity, the accuracy of judgment of severe calcified stenosis is not good, and the use of contrast medium is required.
Digital Subtraction Angiography (DSA)
DSA is the current gold standard for diagnosing vascular stenosis.
It can observe the degree, location, morphology and extent of stenosis, and can dynamically observe the blood flow within the vertebral artery.
DSA cannot accurately visualize wall lesions such as plaque composition and wall thrombus, and is invasive.
It is usually performed in conjunction with percutaneous endovascular intervention.
Differential Diagnosis
Meniere’s disease
Similarities: Vertigo and tinnitus are common.
Differences
Ménière’s disease is mostly a sudden onset of rotational vertigo, which is not accompanied by impaired consciousness and quadriplegia. Symptoms may be alleviated by closing the eyes, and there is no other neurological localization of signs except vertigo and hearing loss of varying degrees.
There is no atherosclerosis on vascular ultrasonography, and no brain lesions on MRI or CTA.
Neurological disorders
Similarities: both may present with vertigo, nausea and blurred vision.
Differences
Patients with neurosis have a wide range of symptoms, including cardiovascular, gastrointestinal, respiratory, and other symptoms, and may have mood changes.
There is no atherosclerosis manifestation in vascular ultrasonography, and no brain lesions in MRA, CTA and other examinations.
Treatment
Aim of treatment: delay the progress of the disease, improve blood supply to the brain, reduce and avoid cerebral blood supply insufficiency and cerebral infarction. Treatment principle: asymptomatic patients mainly control risk factors and medication; symptomatic patients, medication with endovascular treatment.
Thrombolytic therapy
Indications: acute posterior circulation cerebral infarction occurs, and within the time window of thrombolysis.
Commonly used drugs: alteplase, urokinase, etc.
Time window: intravenous alteplase within 4.5 hours of onset, and possibly urokinase within 4.5 to 6 hours.
Adverse effects: use with caution in the presence of bleeding or bleeding tendencies, thrombocytopenia.
Medication
Pharmacologic therapy depends on the etiology of the vertebral stenosis, coexisting clinical disease, and the choice of hemodialysis regimen as prescribed by the physician.
Lipid-lowering drugs
Aims of treatment: to regulate blood lipids, stabilize atherosclerotic plaques, and reduce the risk of plaque dislodgement.
Commonly used drugs: statins (Rosuvastatin, lovastatin, etc.), nicotinic acid drugs (niacin, acyclovir, etc.), fibrates (fenofibrate, benzafibrate, etc.).
Precautions: Intensive lipid-lowering, targeting LDL cholesterol ≤1.8 mmol/L.
Adverse effects: Possible liver function abnormalities, constipation, abdominal pain, myalgia, sensation of skin flushing and itching.
Antiplatelet aggregation drugs
Therapeutic purpose: Inhibit the adhesion and aggregation stage of platelet thrombosis process, so as to avoid thrombosis.
Commonly used drugs: aspirin, etc., clopidogrel, prasugrel, etc., sargramostim, etc.
Precautions: 2 antiplatelet drugs (dual antiplatelet) are usually used in combination after stenting.
Adverse reactions: headache, dizziness, redness of the face, gastrointestinal discomfort, bleeding of the skin mucosa, gastrointestinal bleeding, etc. may occur.
Anti-inflammatory treatment
Therapeutic purpose: Inhibit the immune response of blood vessel wall, applicable to vertebral artery stenosis caused by arteritis.
Commonly used drugs: prednisone, methotrexate, cyclophosphamide, etc.
Adverse reactions: blood pressure, blood sugar abnormalities, peptic ulcer, electrolyte disorders, liver and kidney function abnormalities, bone marrow suppression, pulmonary fibrosis, etc. may occur.
Antihypertensive drugs
Aim of treatment: control blood pressure, delay the progress of the disease, applicable to the combination of hypertension.
Commonly used drugs: hydrochlorothiazide, captopril, propranolol, metoprolol, nifedipine and so on.
Precautions: It is appropriate to maintain the blood pressure below 140/90 mmHg, but too drastic changes in blood pressure should be avoided.
Adverse reactions: Hypokalemia, rash, pruritus, palpitation, cough, edema, etc. may occur.
Hypoglycemic drugs
Treatment purpose: control blood sugar, delay the progress of the disease, applicable to the combination of diabetes mellitus.
Commonly used drugs: insulin preparations, metformin, acarbose, glibenclamide, etc.
Precautions: Strictly follow the doctor’s instructions for medication to avoid hypoglycemia.
Adverse reactions: insulin can be injected local redness, swelling, itching and other allergic reactions and local subcutaneous lipid hyperplasia. Other drugs can appear nausea, diarrhea, loss of appetite, gastrointestinal flatulence, liver function impairment and so on.
Endovascular treatment
Indications
Vertebral artery stenosis severe collateral circulation ring is difficult to compensate, the effect of drug treatment is not good.
Vertebral artery stenosis due to aortitis inflammatory activity control for more than two months.
Commonly used methods and characteristics
It mainly includes balloon vasodilatation with stenting.
Stent implantation reduces the incidence of vascular entrapment and acute vascular occlusion compared with balloon dilatation alone, and the degree of long-term patency is significantly higher.
Drug-coated stents have a higher degree of long-term patency than bare metal stents.
Bare-metal stents are indicated when prolonged dual-antibody therapy is not tolerated.
Surgery
The deep location of the vertebral arteries makes surgical procedures more invasive and associated with a higher complication rate, and should only be used as an alternative to failed interventional therapy.
Prognosis
Cure
The prognosis depends on the control of risk factors, the degree of stenosis and the blood supply to the brain.
Symptomatic vertebral artery stenosis has a 5% to 11% risk of stroke or death within one year of onset.
Restenosis after vertebral stenosis intervention occurs mainly within 1 year after the procedure.
Hazards
It can lead to accidental injuries such as falls, burns, and traffic accidents due to symptoms such as vertigo, blurred vision, and limb weakness.
Sequelae such as limb paralysis, speech and swallowing disorders may occur, and in severe cases, death may result.
Daily
Daily Management
Dietary management
Balanced diet, choose a variety of foods to achieve reasonable nutrition to ensure adequate nutrition and appropriate weight.
Use more cooking methods with less salt and oil, such as steaming, boiling, mixing, water-slipping and simmering, which are easy to digest and absorb.
Eat more vegetables, fruits and whole grains.
Avoid foods that contain a lot of salt, such as salted meat, salted vegetables and other foods.
Avoid spicy and stimulating foods, such as chili peppers, coffee and strong tea.
For those who have difficulty swallowing, eat pureed or pasty foods.
Quit smoking and drinking.
Life management
Appropriate exercise can be done under the guidance of physician after the disease is stabilized.
Blood pressure, blood sugar, blood lipid and other indicators should be strictly controlled to reach the ideal range.
Avoid exertion and take rest.
Avoid fluctuation of blood pressure due to excessive emotional fluctuation, which may cause cerebral ischemia.
Disease monitoring
Monitor changes in symptoms such as headache, dizziness, muscle weakness and sensory loss.
Monitor and control blood pressure, blood lipid and blood sugar.
Follow-up and review
Non-surgical treatment patients should follow the doctor’s instructions for regular review, usually once every 1 to 3 months, in order to adjust the treatment program. Review items include blood lipid, blood glucose, transcranial Doppler ultrasound, magnetic resonance imaging and so on.
Restenosis after intervention mainly occurs within 1 year after surgery. Follow-up visits are recommended at 1, 3, 6, and 12 months after the procedure, and then every 6 months to assess whether restenosis has occurred.
Prevention
Low-salt and low-fat diet, abstain from smoking and alcohol.
Live a regular life, get enough rest, and avoid over-exertion.
Physical exercise more than 5 days a week, 30-45 minutes of aerobic exercise, such as brisk walking, jogging, etc. every day.
Maintain normal body weight, with body mass index (BMI) controlled at 18.5～23.9kg/m2.
Have regular medical checkups to monitor blood pressure, blood glucose, blood lipids, and vascular ultrasound.
Attention should be paid to safety in daily life, avoiding sudden and vigorous activities of the head and neck to avoid causing loss of consciousness and dizziness, which can cause falls and create danger.