Transient ischemic attack in the vertebro-basilar circulation due to a hemodynamically significant variation – kinking of the extracranial section of the left vertebral artery

Abstract

Abstract:We present a case report of a 74-year old female patient with the clinical diagnosis of transient ischemic attack (TIA) in the vertebro-basilar (VB) circulation, in whom we found bilateral variation of the extracranial section of vertebral arteries on ultrasound, on the left side to the extent of kinking. This fi nding was later confi rmed by magnetic resonance angiography (MRA). We discuss the presumed hemodynamic signifi cance of this variation and its etiological relation to the patient's clinical picture. Ultrasound examination of the carotid and vertebro-basilar circulations is an important examination technique contributing to an early detection of possible aetiology of the cerebral circulation disorders (Fig. 7 A transient ischemic attack (TIA) is an acute episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction. A group of cerebrovascular experts proposed a shift from the arbitrary time-based defi nition of TIA to a tissue-based defi nition in 2002 with a new defi nition for TIA as "a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of an acute infarction". (1) This proposed new defi nition was well received and endorsed by many clinicians. The American Heart Association and American Stroke Association (AHA/ASA) 2009 Guidelines endorsed this new defi nition, modifying it with the omission of the phrase "typically less than one hour," as there is no time cut-off that reliably distinguishes whether a symptomatic ischemic event will result in tissue infarction. The AHA/ASAendorsed defi nition of TIA is following: Transient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without an acute infarction (2).TIA in the vertebro-basilar (VB) circulation is characterized by vertigo, nausea, vomiting, double vision, ataxia, dysarthria, dysphagia and bilateral or alternating disturbances of movement or sensory functions. An isolated vertigo may be the initial symptom; however, a combination of symptoms is more typical (3).Atherosclerosis of the major vessels has been the cause of TIA in the VB circulation in 31 % of patients, followed by embolism from the heart (27 %), intra-arterial embolism (17 %), affection of the smaller vessels (16 %), and a number of more uncommon causes (9 %). Stenotic changes in the VB circulation may cause the symptom onset by a hemodynamic mechanism; frequently there are short, stereotypic, and predominantly orthostatic TIAs. Compression or stretching of the vertebral arteries due to the degenerative changes in the cervical spine, depending on position of the head, may also result in perfusion disturbances; retrofl ection, rotation, and their combination in particular, are of the highest risk (4). The ischemia often manifests itself at rest and early in the morning, when there usually is a physiological lowering of the ...

Association of Carotid and Vetebral Arterial Variations with Risk of Ischemic Stroke

“…Apart from the work discussed above, the association between vertebral arterial variations and ischemic stroke has rarely been reported. In 2013, Wagnerova presented a case report of a 74-year-old female patient with a clinical diagnosis of TIA in the vertebrobasilar circulation in whom the author found a bilateral variation of the extracranial section of the vertebral arteries [22]. Another case report suggested that vertebrobasilar tortuosity combined with cerebrovascular risk factors, might have led to vascular vertigo in two patients [23].…”

Surgically Important Relationships of Recurrent and Nonrecurrent Laryngeal Nerves to the Coexisting Variant Vessels

“…Therefore, preoperative diagnosis of RERSA in cancer esophagus patients based on symptoms as dysphagia lusoria or imaging methods may help to avoid injury of the aberrant artery [6]- [9]. The V1 segment of the right vertebral artery in the present case was kinked and therefore, it could impact the diagnosis and treatment of cerebral ischemia [13].…”