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Role of Cerebral Angiography in Vertebrobasilar Occlusive Disease

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Role of Cerebral Angiography in Vertebrobasilar Occlusive Disease J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.6.601 on 1 June 1975. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry, 1975, 38, 601-612 Role of cerebral angiography in vertebrobasilar occlusive disease LOUIS R. CAPLAN AND ARTHUR E. ROSENBAUM From the Departments of Neurology and Radiology, Harvard Medical School, The Beth Israel Hospital, and the Peter Bent Brigham Hospital, Boston, Massachusetts, U.S.A. SYNOPSIS The authors attempt to separate clinical subgroups of patients within the larger category of vertebrobasilar artery disease, and to indicate the present role of angiography in their recognition and management. Angiography is of use in separating posterior fossa occlusive vascular lesions from space occupying lesions. In addition, by defining the locus and nature of the occlusive process, it may result in more rational treatment and prognostication. Subgroups of vertebrobasilar ischaemia which have a favourable prognosis may be separable clinically or, in unclear cases, angiographically. Recognition and description of clinical syn- infarction in the brain-stem related to small Protected by copyright. dromes of brain-stem infarction flourished in the vessel disease associated with hypertension: the late 19th and early 20th centuries (Weber, 1863; dysarthria-clumsy hand syndrome (Fisher, 1967), Jackson, 1864; Raymond and Cestan, 1901; pure motor hemiplegia (Fisher and Curry, 1965), Wallenberg, 1901). It was not until 1946, how- pure sensory stroke (Fisher, 1965b), and homo- ever, that Kubik and Adams described occlusion lateral ataxia and crural paresis syndrome of the basilar artery in postmortem examina- (Fisher and Cole, 1965). These syndromes have tions. These authors emphasized a dire prognosis. a favourable outlook for recovery. Despite Subsequent reports described the clinical picture, numerous episodes of vertebral insufficiency, not which was called vertebrobasilar insufficiency a single case of pathologically documented (Denny-Brown, 1953; Siekert and Millikan, brain-stem infarction was found in a review of 1955; Fang and Palmer, 1956; Williams and over 100 cases of subclavian steal syndrome Wilson, 1962; Williams, 1964); Browne and (North et al., 1962; Patel and Toole, 1965; Poskanzer (1969), in a review of stroke treat- Wheeler, 1967; Baker et al., 1973). The pure ment, also emphasized the grave nature of the syndromes of lateral medullary or lateral pon- http://jnnp.bmj.com/ disease: 'If anticoagulation has value, it may be tine infarction also have a good prognosis more useful in the patient with vertebrobasilar (Currier et al., 1958). Fisher (1970) has pointed disease, with its high mortality, than in other out that occlusion of the vertebral artery in the forms of cerebral vascular thrombosis'. neck commonly produces transient symptoms Marshall's (1964) review of the natural history but rarely produces brain-stem infarction unless of transient ischaemic attacks uncovered a the vertebral artery is occluded intracranially. relatively better prognosis for patients with Thus it must be clear that vertebrobasilar disease vertebrobasilar ischaemic episodes than for is not a homogeneous entity; some clinical on September 29, 2021 by guest. those patients with carotid ischaemia. Further- subgroups have relatively better prognoses than more, several groups of patients with ischaemic others. disease of the posterior cerebral circulation The outcome in any given patient with poster- seem to have a relatively good prognosis. Fisher ior circulation occlusive disease is dependent on: described several syndromes produced by lacunar (1) the particular anatomy of the vertebrobasilar Address for correspondence: Dr Louis R. Caplan, Department of circulation (developmental variations are very Neurology, Beth Israel Hospital, Boston, Massachusetts 02215, and U.S.A. common); (2) the locus rapidity of the (Accepted 10 February 1975.) occlusive process; (3) the physiological state of 601 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.6.601 on 1 June 1975. Downloaded from 602 Louis R. Caplan and Arthur E. Rosenbaum 2a 2b [ i I-- 1 Protected by copyright. 6__ 3 51%.F A http://jnnp.bmj.com/ ...... A I on September 29, 2021 by guest. FIG. 1 Majorforms ofvascular occlusion in the posterior circulation. 1. Medial hypertrophy ofsmall arteries. 2. Obstruction of major vessel branches: a. atheroma in lumen ofparent vessel blocking orifice; b. atheroma extending into branch; c. thrombotic occlusion of branch. 3. Occlusion of vessel proximal to branch origin. 4. Stenosis of large vessel by atheroma. 5. Embolic occlusion of vessel. 6. In situ thrombosis complicating atheromatous stenosis of a large vessel. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.6.601 on 1 June 1975. Downloaded from Role of cerebral angiography in vertebrobasilar occlusive disease 603 the systemic circulation and haematological integrity of other branches and the general state system; and (4) the availability of adequate of the circulation. collateral circulation; congenitally deficient or With the frequent use of selective vertebral previously obstructed cranial and extracranial angiography and magnification radiography, it vessels may diminish available collateral vessels. is now possible to define the individual anatomy Six major types of vascular pathology may be and vascular pathology in many cases of seen in occlusive disease of the posterior cerebral posterior circulation occlusive disease. By circulation (Fig. 1): (1) disruption of small defining the vascular lesion, angiography may penetrating branches of vessels as seen in hyper- help the clinician not only to prognosticate but tension or arteritis (Fisher, 1969); (2) obstruc- to select the most appropriate treatment. Angio- tion of branch vessels produced by atheroma graphy also may help separate occlusive vascular blocking the origin of the branches or by disease from haemorrhage or tumour of the intrinsic atheroma or thrombosis of the larger posterior fossa. In this paper, we analyse 11 branches themselves; (3) occlusion of a vessel recent cases of occlusive vascular disease of the proximal to the origin of the branch (Fisher et posterior circulation studied clinically and al., 1961); (4) major stenosis of the intracranial angiographically to illustrate the role of angio- vertebral arteries bilaterally or of the basilar graphy in clinical management ofvertebrobasilar artery; (5) thromboembolic occlusion of major disease. cerebral vessels arising from the heart, aortic arch, or vertebral arteries; (6) in situ thrombosis CASE 1 of the vertebrobasilar Protected by copyright. arteries themselves. It S.M., a 55 year old insulin-dependent, diabetic seems likely that the last three pathological gypsy man had a 14 year history of hypertension and entities would be associated with more serious three previous myocardial infarctions. A stroke had infarction and a more grave clinical outcome. produced left hemiparesis which cleared after a few Also these varying pathologies would probably months. One day before admission, he awakened respond quite differently to therapeutic endeav- with dysarthria and right facial weakness which re- ours such as anticoagulation. Castaigne et al. solved in 30 minutes. The next day dizziness, right (1973) have reviewed the loci and nature of facial weakness, and dysarthria recurred but fluc- vascular changes in patients with occlusions in tuated during the day until right hemiplegia devel- the vertebrobasilar system discovered during oped. Examination revealed complete right hemi- postmortem examinations. plegia and shivering of his left limbs. The next day he became quadriplegic and developed bifacial paresis, The clinical differentiation between small and dysphagia, and severe dysarthria. Electroencephalo- large vessel disease is frequently difficult. graphy was normal. Transfemoral cerebral angio- Occlusions of small, penetrating branch-vessels graphy (Figs 2a-c) demonstrated no filling of the generally occur in hypertensive patients. The basilar artery above the level of the anterior inferior http://jnnp.bmj.com/ anatomy of the infarct is usually limited to cerebellar arteries. The left posterior inferior cere- territories a bellar artery filled the left superior cerebellar artery supplied by single median, para- resulting in retrograde opacification of the upper median, or circumferential vessel. Small vessel basilar artery. Bilateral carotid angiography showed lesions are usually not accompanied by promi- no supratentorial circulatory abnormality. He was nent headache, and the duration of time between placed on anticoagulation therapy and was able to original ischaemic symptoms and completed walk with help 11 months later. No additional stroke is usually short (hours to weeks). In con- ischaemic episodes have occurred in the 33 months on September 29, 2021 by guest. trast, large vessel disease-for example, basilar since the original stroke. artery-often produces bilateral signs not pro- duced by occlusion of a single penetrating COMMENT The presence of hypertension and branch: the symptomatic period may be pro- diabetes suggested either small or large vessel longed, the symptoms more variegated and less disease in this patient. The clinical picture, how- stereotyped, and headache may be prominent. ever, was more compatible with large vessel Branch occlusion may be attended by more occlusion of the basilar artery. He was a sub- widespread signs, however, depending on the optimal candidate for anticoagulation
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