Vertebral artery syndrome is a series of disorders of a vestibular, vascular and vegetative nature arising from pathological narrowing of the vertebral artery. Most often it has a vertebrogenic etiology. It is clinically manifested by recurrent syncopal states, attacks of basilar migraine, TIA, Barre-Lieu syndrome, ophthalmic, vegetative, vestibulocochlear and vestibulo-atactic syndromes. Diagnosis is facilitated by radiography and REG with functional tests, MRI and CT of the spine and brain, ophthalmoscopy, audiometry, etc. Therapy includes the use of venotonics, vascular and neuroprotective drugs, symptomatic agents, massage, physiotherapy, physical therapy.
ICD 10
M47.0 Compression syndrome of anterior spinal or vertebral artery (G99.2*)
General information
Vertebral artery syndrome (VAS) is a complex symptom complex that occurs when the lumen of the vertebral artery (VA) decreases and its periarterial nerve plexus is affected. According to the collected data, in practical neurology, VAS occurs in 25-30% of cases of cerebral circulatory disorders and is the cause of up to 70% of TIA (transient ischemic attacks). The most significant etiopathogenetic factor in the occurrence of the syndrome is the pathology of the cervical spine, which also has a common character. The high prevalence and frequent occurrence among the able-bodied categories of the population make vertebral artery syndrome an urgent social and medical problem of our time.
Anatomy of the vertebral artery
A person has 2 vertebral arteries. They provide up to 30% of the cerebral blood supply. Each of them departs from the subclavian arteries of the corresponding side, goes to the cervical spine, where it goes through the holes in the transverse processes CVI–CII. Then the vertebral artery makes several bends and passes through the large occipital opening into the cranial cavity. At the level of the beginning of the bridge, the vertebral arteries merge into one main artery. These three arteries form the vertebrobasilar pool (VBP), which supplies blood to the cervical segments of the spinal cord, the medulla oblongata and the cerebellum. Through the wellisium circle, the VBP interacts with the carotid pool, which supplies blood to the rest of the brain.
In accordance with the topographic features of the VA, its extra- and intracranial departments are distinguished. Most often, vertebral artery syndrome is associated with damage to the extracranial artery. Moreover, it can occur not only with compression and other changes of the artery itself, but also with adverse effects on its vegetative perivascular sympathetic plexus.
Causes
Vertebral artery syndrome of compression etiology is most common. It is caused by extravasal factors: osteochondrosis of the spine, vertebral instability, cervical spondyloarthrosis, intervertebral hernias, tumors, structural anomalies (platybasia, Klippel-Feil syndrome, Kimberly anomaly, anomalies of the structure of the I cervical vertebra, basilar impression), tonic tension of the cervical muscles (long, ladder, lower oblique). At the same time, VAS often develops not due to narrowing of the artery lumen due to its mechanical compression, but as a result of reflex spasm caused by the compressive effect on the sympathetic periarterial plexus.
In other cases, the syndrome of the vertebral artery occurs due to its deformation — abnormalities of the structure of the vascular wall, the presence of kinks or kinking (pathological tortuosity). Occlusive VA lesions in atherosclerosis, systemic vasculitis, embolisms and thrombosis of various genesis are another group of VAS etiofactors. Due to the existing compensatory mechanisms, the impact of only extravasal factors rarely leads to the development of a VAS. As a rule, the syndrome is observed if compression of the artery occurs against the background of pathological changes in its vascular wall (hypoplasia or atherosclerosis).
Classification
Pathogenetically, VAS is classified according to the type of hemidynamic disorders. According to this classification, compression-type vertebral artery syndrome is caused by mechanical compression of the artery. The angiospastic variant occurs with reflex spasm caused by irritation of the receptor apparatus in the area of the affected vertebral segment. It is manifested mainly by vegetative-vascular disorders, weakly dependent on head movements. Irritative VAS occurs when the fibers of the periarterial sympathetic plexus are irritated. The vertebral artery syndrome is most often of a mixed nature. The compression-irritative type of VAS is typical for the lesion of the lower cervical region, and the reflex type is associated with pathology of the upper cervical vertebrae.
The clinical classification divides VAS into dystonic and ischemic, which represent the stages of one pathological process. The dystonic variant is functional. At this stage, the clinical picture is characterized by cephalgia (headache), cochleo-vestibular and visual symptoms. Cephalgia is pulsating or aching, accompanied by vegetative symptoms, is constant with periods of intensification, often provoked by movements in the neck or its forced position.
Ischemic VAS is an organic stage, i.e. it is accompanied by morphological changes in cerebral tissues. ACVA is clinically manifested in the vertebrobasilar basin, which may be transient (reversible) in nature or cause persistent neurological deficiency. In the first case, they talk about TIA, in the second — about an ischemic stroke. At the ischemic stage of VAS, vestibular ataxia, nausea with vomiting, dysarthria are observed. Transient ischemia of the brain stem leads to a drop attack, a similar process in the zone of the reticular formation leads to syncopal paroxysm.
Symptoms
Usually, the symptoms of VAS are a combination of several of the following options, but one specific syndrome may take the leading place.
Basilar migraine occurs with cephalgia in the occipital region, vestibular ataxia, repeated vomiting, tinnitus, sometimes dysarthria. Often basilar migraine manifests itself as a classic migraine with aura. The aura is characterized by visual disturbances: flickering spots or rainbow stripes located in both eyes, blurred vision, the appearance of “fog” in front of the eyes. By the nature of the aura, basilar migraine is ophthalmic.
The Barre —Lieu syndrome is also called posterior-cervical sympathetic syndrome. There are pains in the neck and back of the head, passing to the parietal and frontal parts of the head. Cephalgia occurs and increases after sleep (in the case of an unsuitable pillow), head turns, shaking riding or walking. It is accompanied by vestibulocochlear, vegetative and ophthalmic symptoms.
Vestibulo-atactic syndrome — dizziness, provoked by turning the head, prevails. Vomiting, episodes of darkening in the eyes are noted. Vestibular ataxia is expressed in a feeling of instability during walking, staggering, and imbalance.
Ophthalmic syndrome includes fatigue of vision under stress, transient flickering scotomas in the field of vision, transient photopsias (short-term flashes, sparks in the eyes, etc.). Temporary partial or complete bilateral paroxysmal loss of visual fields is possible. Some patients have conjunctivitis: redness of the conjunctiva, pain in the eyeball, a feeling of “sand in the eyes”.
Vestibulocochlear syndrome is manifested by dizziness, a feeling of instability, permanent or transient tinnitus, the nature of which varies depending on the location of the head. There may be a slight degree of hearing loss with a violation of the perception of whispered speech, which is reflected in the audiogram data. Paracuse is possible — a better perception of sounds against the background of noise than in complete silence.
The syndrome of autonomic disorders is usually combined with other syndromes and is always observed in periods of acute VAS. It is characterized by hot or cold flushes, hyperhidrosis, cooling of the distal extremities, a feeling of lack of air, tachycardia, blood pressure drops, chills. Sleep disorders may occur.
Transient ischemic attacks characterize organic VAS. The most typical are temporary motor and sensory disorders, homonymous hemianopia, dizziness with vomiting, non-vertigo-induced vestibular ataxia, diplopia, dysarthria and dysphagia.
Unterharnscheidt syndrome is a short—term “disconnection” of consciousness provoked by a sharp turn of the head or its uncomfortable position. The duration may vary. After regaining consciousness, weakness in the limbs persists for some time.
Drop attacks are episodes of transient sharp weakness and immobility of all four limbs with a sudden fall. Occur when the head is thrown back quickly. Consciousness remains intact.
Diagnostics
Vertebral artery syndrome is diagnosed by a neurologist, additionally, it is possible to consult the patient with an otolaryngologist, ophthalmologist, vestibulologist. During examination, signs of autonomic disorders may be detected, in the neurological status — instability in the Romberg pose, slight symmetrical discoordination when performing coordination tests. Cervical spine x-ray is carried out with functional tests in 2 projections. It determines a variety of vertebral pathology: spondylosis, osteochondrosis, hypermobility, subluxation of articular processes, instability, structural anomalies. If it is necessary to obtain more accurate information, a CT scan of the spine is performed, and an MRI of the spine is performed to assess the condition of the spinal cord and its roots.
In order to study vascular disorders accompanying VAS, rheoencephalography with functional tests is performed. As a rule, it diagnoses a decrease in blood flow in the VBP, which occurs or increases during rotational tests. Currently, REG is giving way to more modern blood flow studies — duplex scanning and ultrasound of the vessels of the head. MRI of the brain allows to establish the nature of morphological changes in cerebral tissues that have arisen as a result of ACVA in the organic stage of VAS. According to the indications, visiometry, perimetry, ophthalmoscopy, audiometry, caloric test, and other studies are carried out.
Treatment
In cases where vertebral artery syndrome is accompanied by ACVA, urgent hospitalization of the patient is necessary. In other cases, the choice of regime (inpatient or outpatient) depends on the severity of the syndrome. In order to reduce the load on the cervical spine, it is recommended to wear a Trench collar. To restore the proper anatomical location of the structures of the cervical spine, it is possible to use soft manual therapy, to relieve tonic tension of the neck muscles — postisometric relaxation, myofascial massage.
Pharmacotherapy usually has a combined character. First of all, drugs are prescribed that reduce swelling, aggravating VA compression. These include troxorutin and diosmin. In order to restore normal blood flow in the VA, pentoxifylline, vinpocetine, nimodipine, cinnarizine are used. The administration of neuroprotective drugs (pig brain hydrolysate, meldonium, ethylmethylhydroxypyridine, piracetam, trimetazidine) is aimed at preventing metabolic disorders of brain tissues in patients at risk of cerebral ischemia. Such therapy is especially relevant in patients with TIA, drop attacks, Unterharnscheidt syndrome.
At the same time, depending on the indications, symptomatic therapy with antimigrenous drugs, antispasmodics, muscle relaxants, vitamins g. B, histamine-like drugs is carried out. The positive effect is provided by the use of additional therapeutic methods of physiotherapy (ultraphonophoresis, magnetotherapy, electrophoresis, DDT), reflexotherapy, massage. Outside of the acute phase of the VAS, physical therapy classes are recommended to strengthen the neck muscles.
If it is impossible to eliminate the etiological factor, insufficient effectiveness of conservative measures, the threat of ischemic brain damage, the question of surgical treatment is considered. Surgical decompression of the vertebral artery, removal of osteophytes, reconstruction of the vertebral artery, periarterial sympathectomy is possible.
