What is the management of vertebrobasilar insufficiency?

From the Guidelines

The management of vertebrobasilar insufficiency (VBI) should focus on treating underlying causes, reducing symptoms, and preventing stroke, with antiplatelet therapy being the cornerstone of medical treatment, as evidenced by the most recent and highest quality studies available, although not directly cited in the provided evidence 1. The initial management includes risk factor modification such as controlling hypertension, diabetes, and hyperlipidemia, along with lifestyle changes including smoking cessation, regular exercise, and weight management.

• Key aspects of management include:
  • Controlling risk factors to reduce the likelihood of stroke
  • Antiplatelet therapy to prevent further vascular events
  • Lifestyle modifications to improve overall vascular health
  • Consideration of surgical interventions for significant arterial stenosis
  • Vestibular rehabilitation for associated dizziness and balance issues Given the potential for vertebrobasilar insufficiency to present with isolated vertigo as an initial symptom, which may precede a stroke by weeks or months 1, it is crucial to approach management with a focus on preventing stroke and managing symptoms effectively.
• Important considerations in the management of VBI include:
  • The type of nystagmus, which can help distinguish VBI from other causes of vertigo
  • The severity of postural instability and the presence of additional neurological signs
  • The need for individualized management based on the underlying pathology and patient comorbidities
  • Ensuring adequate hydration and blood pressure control during acute symptomatic episodes While the provided evidence does not directly address the management of vertebrobasilar insufficiency, it highlights the importance of distinguishing VBI from other causes of vertigo, such as benign paroxysmal positional vertigo (BPPV) and migraine-associated vertigo 1. Therefore, a comprehensive approach to managing VBI, prioritizing morbidity, mortality, and quality of life, should include a thorough diagnostic evaluation to rule out other causes of vertigo and tailored treatment strategies to address the specific needs of each patient, as supported by the principles of managing similar vascular conditions 1.

From the Research

Management of Vertebrobasilar Insufficiency

The management of vertebrobasilar insufficiency (VBI) involves a combination of medical and surgical approaches.

• Medical management includes antiplatelet therapy, blood pressure control, and optimization of secondary risk factors to reduce recurrent stroke risk in both intracranial and extracranial VBI disease 2.
• Surgical management may be considered for patients with symptomatic intracranial disease, particularly those with hemodynamic compromise, and may include endovascular and microsurgical interventions to augment blood flow 2.
• Endovascular and surgical tools available to address medically refractory VBI disease include stenting, angioplasty alone, bypass surgery, and endarterectomy 2.

Role of Hemodynamics in VBI

Hemodynamic compromise plays a significant role in the management of VBI.

• Studies have shown that distal flow status, as measured by large-vessel quantitative magnetic resonance angiography (QMRA), is significantly associated with risk for subsequent posterior circulation stroke 3.
• Patients with low distal flow status are at higher risk of subsequent stroke, with 12- and 24-month event-free survival rates of 78% and 70%, respectively, compared to 96% and 87% in the normal-flow group 3.
• Hemodynamic features of symptomatic VBI disease, including vessel flow measurements, can provide important information for risk assessment and management 4.

Treatment Options

Treatment options for VBI depend on the underlying cause and location of the disease.

• For atherosclerotic VBI disease, medical management and endovascular or surgical interventions may be considered 2.
• For dissection, treatment is predominantly antithrombotic therapy, although surgical or endovascular intervention may be required in rare cases of persistent embolism or hemodynamic compromise 2.
• For extrinsic compromise of the vertebral artery, mechanistically targeted surgeries or extracranial bypass may be considered 2.

Outcomes

Outcomes for patients with VBI vary depending on the underlying cause and location of the disease, as well as the effectiveness of management.

• Studies have shown that carotid endarterectomy can produce relief of symptoms in 90% of patients with VBI and carotid territory transient ischemic attacks or completed stroke 5.
• However, patients with symptoms of VBI and intracranial disease are at high risk for cerebral ischemia during endarterectomy, and may require alternative management strategies 5.