DIAGNOSIS OF VERTEBROBASILAR INSUFFICIENCY USING

TRANSCRANIAL DOPPLER ULTRASOUND

Sean StewardFebruary 20, 2013

Overview

Vertebrobasilar Insufficiency Signs and Symptoms Risk Factors

Tests Transcranial Doppler Ultrasound Case Study QA statistics of TCD Conclusion

Vertebrobasilar Insufficiency

Vertebrobasilar insufficiency (VBI) is a posterior circulation transient ischemic attack (TIA) caused by intermittent vertebral artery occlusion that is induced by a head rotation or extension

VBI also may result from large vessel atherosclerotic disease, dissection, cervical compressive lesions, and subclavian steal phenomenon

Signs and Symptoms for VBI

Loss of vision in part or all of both eyes Double vision Vertigo (spinning sensation) Numbness or tingling Nausea and vomiting Slurred speech Loss of coordination, dizziness or confusion Trouble swallowing A drop attack — sudden generalized

weakness Ucdavis.edu

Risk Factors for VBI

Smoking Hypertension Hyperlipidemia Older age Gender: men have a higher risk before

age 75; women have a high risk after 75 Family history Genetic factors

Ucdavis.edu

Tests Magnetic Resonance Angiography (MRA) Standard angiography (X-ray study using injected dye)

Both are used to identify vertebrobasilar artery disease Digital Subtraction Cerebral Angiography (DSA) is considered the

“gold standard” diagnostic test Mild sedative is used Electrocardiogram is attached Catheter placed starting in the groin Contrast material DSA uses a computer to "subtract" or take out the bones and tissues in

the area viewed, so that only the blood vessels filled with the contrast dye are seen

Ucdavis.edu Nlm.nih.gov

Transcranial Doppler

Typically use a 2 MHz probe Angle of insonation is zero

degrees (3) most common windows

utilized: Transforamenal (A) Transtemporal (B) Transorbital (C)

Standard method of quantifying velocity is time averaged mean velocity (TAMV) McPharlin & Rumwell

A

B

C

Transcranial Doppler

Accurate vessel identification Appropriate sample volume and depth Direction and velocity of blood flow

McPharlin & Rumwell

Case Study

50 year old Caucasian male Presented with one year of positional vertigo

and ataxic gait when extending his neck Positional vertigo is a sudden sensation of

spinning with head movements Ataxic gait is an unsteady, uncoordinated walk

CT and MRI were WNL TCD performed

nlm.nih.gov thefreedictionary.com ncbi.nlm.nih.gov

Case Study

TCD monitoring of the bilateral PCA (Posterior Cerebral Artery) mean flow velocities were monitored in different head positions using a head frame to avoid any changes in the angle of insonation ncbi.nlm.nih.gov

Case Study

Transforamenal window was used to image the vertebral arteries and basilar arteries

Transtemporal window was used to evaluate the posterior cerebral arteries In an upright position the mean velocities for

the right and left PCA’s were 18cm/sec and 19cm/sec ncbi.nlm.nih.gov

Case Study

After the TCD imaging was performed: An electronystagmography (ENG) was performed

which was negative Electronystagmography (ENG) is used to evaluate people

with vertigo (a false sense of spinning or motion that can cause dizziness) and certain other disorders that affect hearing and vision

An MRI of his cervical spine was done to rule out myelopathy Myelopathy is a term used to describe symptoms related

to spinal cord compression Cervical (neck) myelopathy is most common

hopkinsmedicine.org piedmonthospital.org ncbi.nlm.nih.gov

Case Study

Review: (2) MRI’s (Both negative) CT (Negative) ENG (Negative) ENT (Ear nose and throat work up – Negative) TCD (Showed positive results…thank you very

much) Patient refused spinal surgery and is being

treated conservatively

ncbi.nlm.nih.gov

QA Statistics

According to a series that was done in 1992 that compared TCD with DSA (Gold Standard) in 20 patients the results are as follows for TCD: Sensitivity – 87% Specificity – 80% Positive Predictive Value – 93% Negative Predictive Value – 67%

The results proved that TCD is a useful screening method in patients with VBI to detect large vessel disease of the intracranial vertebrobasilar system

ncbi.nlm.nih.gov

Conclusion

VBI is a very difficult disease to diagnose TCD should be the new “Gold Standard”

diagnostic test for evaluating VBI’s It’s noninvasive

No sedative, catheter, contrast dye, ECG Relatively inexpensive test Can go bedside if needed Proven QA numbers

References

  Alnami, I., Siddiqui, M. & Saqqur, M. (2012, November).Case Reports in Medicine. TheDiagnosis of Vertebrobasilar Insufficiency Using Transcranial Doppler Ultrasound.Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509548/

Ataxic gait (n.d.) The free dictionary. Retrieved from: http://medical-dictionary.thefreedictionary.com/ataxic+gait

Benign positional vertigo (n.d.).Medline Plus.Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/001420.htm

Cerebral angiography (n.d.).Medline Plus.Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/003799.htm

References

Electronystagmography (ENG) (n.d.) John Hopkins Medicine. Retrieved from:http://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/electronystagmography_eng_92,P07659/

McPharlin, M., & Rumwell, C. (2009). Vascular Technology: An Illustrated Review. Pasadena, CA:Davies Publishing, Inc.

Myelopathy (n.d.) Piedmont Healthcare. Retrieved from:http://www.piedmonthospital.org/SpineCenter/Myelopathyctr.aspx

UCDavis Health System. Vertebrobasilar insufficiency. Retrieved

from:http://www.ucdmc.ucdavis.edu/vascular/diseases/vertebrobasilar.html