Vertebrobasilar artery syndrome

1) Disease Description (Causes and Symptoms)

• Definition and pathophysiology: Stroke is classified into ischemic stroke (cerebral infarction), which occurs when cerebral blood vessels become blocked, cutting off blood flow and oxygen supply to brain tissue, and hemorrhagic stroke (intracerebral hemorrhage and subarachnoid hemorrhage), which occurs when cerebral blood vessels rupture and cause bleeding. Ischemia is caused by thrombosis, embolism, atherosclerosis, and other factors, while hemorrhage is associated with hypertension, aneurysm rupture, vascular malformations, anticoagulants, and other factors.
• Major causes and risk factors: Hypertension (the highest priority), atrial fibrillation (embolic), diabetes, hyperlipidemia, smoking, excessive alcohol consumption, obesity, carotid artery stenosis, blood disorders, and certain hereditary or vascular diseases (e.g., moyamoya disease).
• Main symptoms (particularly important in the acute phase): Sudden weakness or paralysis of one side of the limbs (hemiplegia), language impairment (aphasia), speech impairment (dysarthria), visual field defects or reduced vision, double vision and dizziness (especially with brainstem lesions), dysphagia, severe headache (particularly a “sudden and worst-ever headache” in subarachnoid hemorrhage), and changes in consciousness. Symptoms vary depending on the location and extent of the lesion.

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2) Treatment Methods and Precautions

• Initial (emergency) principles
  • Immediately determine whether bleeding is absent (relatively rapid non-contrast CT) — distinguishing ischemic from hemorrhagic stroke is the highest priority.
  • Transfer the patient promptly to a hospital capable of providing specialized emergency stroke treatment (time is critical for saving brain tissue).
• Ischemic stroke
  • Intravenous thrombolysis (IV tPA, usually alteplase): Administered as soon as possible after symptom onset, generally within 4.5 hours (indications and contraindications must be assessed).
  • Mechanical thrombectomy (acute clot removal, thrombectomy): Generally standard within 6 hours of symptom onset, but when selected based on imaging, it may provide benefits up to 6–24 hours (based on the DAWN/DEFUSE criteria).
  • Antiplatelet agents (such as aspirin): Used after the acute phase and for secondary prevention. In minor or transient ischemic attacks (TIAs), short-term dual antiplatelet therapy may be used (at the physician’s discretion).
  • Anticoagulants: Used in patients with cardioembolic stroke (e.g., atrial fibrillation); the timing of initiation is determined after excluding hemorrhage.
  • Control of blood pressure, blood glucose, body temperature, fluid and electrolyte balance, and other factors, along with prevention of complications.
• Hemorrhagic stroke
  • Urgent blood pressure control (in cases of severe hemorrhage, treatment to lower the target blood pressure is administered); if anticoagulants or antiplatelet agents are being used, reverse their effects immediately (e.g., vitamin K + PCC, dabigatran reversal with idarucizumab, etc.; availability of reversal agents for Xa inhibitors may vary).
  • Surgical treatment: Surgical evacuation may be required for large intracerebral hemorrhages; in cases of subarachnoid hemorrhage, aneurysm clipping or coil embolization may be necessary. If hydrocephalus is present, external ventricular drainage (EVD) may be performed.
  • Prevention and treatment of vasospasm after subarachnoid hemorrhage (including the use of nimodipine), and management based on angiography.
• Common acute-phase treatment and rehabilitation
  • Management in a specialized stroke unit is recommended — it reduces mortality and disability rates.
  • Early rehabilitation from the initial acute phase (physical, occupational, and speech therapy), swallowing assessment, and prevention of aspiration.
• Lifestyle management and prevention
  • Management of hypertension, diabetes, and lipids; compliance with antiplatelet/anticoagulant treatment guidelines; smoking cessation; limiting alcohol consumption; weight management; regular exercise; and management of atrial fibrillation (appropriate administration of anticoagulants).
• Precautions
  • If acute stroke is suspected, visit the emergency room immediately. Accurately reporting the time of symptom onset (or the last known normal time) is crucial in determining eligibility for treatment.
  • Inform medical staff in advance whether anticoagulants or antithrombotic agents are being taken, as well as any history of bleeding, surgery, or allergies.

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3) Checklist Before an Outpatient Visit (Items to Prepare and Sample Questions)

• Items and information to prepare
  • A list of all medications currently being taken (including prescriptions, OTC medicines, herbal medicines, and supplements) and the times they are taken
  • Existing diagnoses and medical history (hypertension, diabetes, atrial fibrillation, carotid artery surgery, etc.)
  • Copies or CDs of previous brain imaging (CT/MRI) and vascular test results (CTA/MRA/angiography)
  • The time of symptom onset (exact time or last known normal time) and a record of the symptom progression (when symptoms began, what they were, and how they changed)
  • Blood pressure and blood glucose records (recent measurements if possible)
  • Allergies and a history related to bleeding or coagulation (e.g., stomach ulcers or anticoagulant use)
• Items the doctor may check during the outpatient visit (useful for the patient to record in advance)
  • The time symptoms began and the type of symptoms (paralysis, language, vision, etc.)
  • Whether symptoms improved or worsened, and whether there was any trauma or medication change
  • Lifestyle habits (smoking, alcohol consumption, exercise) and family history (stroke or cardiovascular disease)
  • Any recent surgery or procedure, or whether anticoagulants are being taken

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4) Examples of General Questions to Ask the Doctor

• “Can we determine for sure whether these symptoms are due to a stroke? What tests are needed?”
• “What are the indications and risks of acute treatments I may receive (thrombolysis or thrombectomy)?”
• “What medication should I take to prevent recurrence, when should I start it, and how long should I take it?”
• “What should I be especially careful about in daily life (exercise, bathing, constipation or coughing, alcohol consumption, etc.)?”
• “How can my prognosis and the possibility of functional recovery (language and motor recovery) be predicted?”

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5) Examples of Disease-Specific Questions (1–2 Questions to Be Sure to Ask the Doctor)

• “I do not know the exact time when my symptoms began (for example, discovering symptoms upon waking). How will you determine whether I am eligible for thrombolysis or thrombectomy?”
• “Because of the risk of bleeding (for example, in someone taking anticoagulants), when should I start medication to prevent recurrence, and could you explain which medication is appropriate?”

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Note: This material provides general medical information. Individual diagnosis and treatment should be discussed with the treating specialist. Acute symptoms (such as sudden one-sided paralysis, language impairment, or severe headache) require an immediate visit to the emergency room.