1. Diagnosis of Vertebrobasilar Insufficiency Using Transcranial Doppler Ultrasound
Sean Steward
February 20, 2013

2. Overview Vertebrobasilar Insufficiency Tests
Signs and Symptoms
Risk Factors
Tests
Transcranial Doppler Ultrasound
Case Study
QA statistics of TCD
Conclusion

3. 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

4. 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

5. 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

6. 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

7. 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

8. Transcranial Doppler Accurate vessel identification
Appropriate sample volume and depth
Direction and velocity of blood flow
McPharlin & Rumwell

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. References
  Alnami, I., Siddiqui, M. & Saqqur, M. (2012, November).Case Reports in Medicine. TheDiagnosis of Vertebrobasilar Insufficiency Using Transcranial Doppler Ultrasound.Retrieved from:
Ataxic gait (n.d.) The free dictionary. Retrieved from:
Benign positional vertigo (n.d.).Medline Plus.Retrieved from:
Cerebral angiography (n.d.).Medline Plus.Retrieved from:

17. References
Electronystagmography (ENG) (n.d.) John Hopkins Medicine. Retrieved from:
McPharlin, M., & Rumwell, C. (2009). Vascular Technology: An Illustrated Review. Pasadena, CA:Davies Publishing, Inc.
Myelopathy (n.d.) Piedmont Healthcare. Retrieved from:
UCDavis Health System. Vertebrobasilar insufficiency.
Retrieved from: