Vertebrobasilar insufficiency

Preliminary Diagnosis: Vertebrobasilar insufficiency

I. What imaging technique is first-line for this diagnosis

• Non-contrast CT of the head with CTA of the head and neck is the first-line imaging modality.

II. Describe the advantages and disadvantages of this technique for diagnosis of vertebrobasilar insufficiency.

Advantages

• Relatively fast and inexpensive imaging modality compared with companion MR/MRA imaging.

• Highly sensitive to hemorrhage.

• Offers exquisite detail of the osseous structures.

• Highly sensitive and specific to detecting and characterizing focal areas of significant hemodynamic stenosis, vascular malformation, or aneurysmal dilatation.

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Disadvantages

• Exposes patients to ionizing radiation.

III. What are the contraindications for the first-line imaging technique?

• CT imaging may be contraindicated in pregnant patients.

• Intravenous contrast in CTA imaging is contraindicated in patients with abnormal renal function and elevated creatinine (institution-dependent) and those not on an adequate dialysis regimen.

IV. What alternative imaging techniques are available?

• MR of the brain according to stroke protocol and contrast or non-contrast MRA of the head and neck.

• Catheter angiography.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of vertebrobasilar insufficiency.

MR of the brain according to stroke protocol and contrast or non-contrast MRA of the head and neck

Advantages

• Highly sensitive and specific in detecting and characterizing focal areas of ischemia or infarction.

• Does not expose patients to ionizing radiation.

Disadvantages

• Expensive

• Time-consuming

• Less sensitive and specific in detecting focal areas of significant hemodynamic stenosis, vascular malformation, or aneursymal dilatation.

• May be subject to motion artifact secondary to length of the exam.

Catheter angiography

Advantages

• Gold standard in diagnosing and treating vertebrobasilar insufficiency.

Disadvantages

• Invasive procedure that is associated with greater morbidity and mortality compared with companion MR or CT imaging.

VI. What are the contraindications for the alternative imaging techniques?

MR of the brain according to stroke protocol and contrast or non-contrast MRA of the head and neck

• Contraindicated in patients with non-MR compatible hardware.

Catheter angiography

• Contraindicated in patients with a severe hypocoagulable state.

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