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Vertebrobasilar Insufficiency

Original Editor - Ahmed M Diab

Top Contributors - Ahmed M Diab, Vidya Acharya and Alexandra Stead  

Introduction

Vertebrobasilar Insufficiency (VBI), also referred to as posterior circulation ischaemia, is a condition characterised by a transient reduction in blood flow through the vertebral and basilar arteries to the posterior structures of the brain[1]. The posterior circulation supplies critical areas including the brainstem, cerebellum, thalamus, and occipital lobes[2].

Anatomy

The vertebrobasilar system is composed of the paired vertebral arteries (VAs) which typically arise from the subclavian arteries. The VAs are divided into four segments:[3][4]

  • V1: Subclavian artery to C6 transverse foramen.
  • V2: Through the foramina from C6 to C1.
  • V3: Between C1 and the foramen magnum.
  • V4: Intradural segment forming the basilar artery

Pathophysiology

VBI results from a reduction in perfusion to the posterior brain structures supplied by the vertebrobasilar system[5]. The most frequent cause is atherosclerosis, with other common causes including embolism, large vessel atherosclerosis, and arterial dissection[1][5].

Mechanisms of vertebrobasilar insufficiency relevant to physiotherapy practice
Mechanism Description Clinical relevance
Atherosclerosis Progressive plaque-related luminal stenosis of vertebral or basilar arteries[5] Most common aetiology; principal risk factors include hypertension, obesity, and smoking[5]
Cervical Artery Dissection Intimal tear creating intramural haematoma with thrombus formation or arterial occlusion[6] Most serious risk in physiotherapy practice; associated with trauma, connective tissue disorders, and spontaneous onset[7]
Mechanical compression (Rare) Osteophytes or uncovertebral joint hypertrophy compressing the V2 foraminal segment[8] May be provoked by cervical rotation and extension; more common in older patients with degenerative change[9]
Embolism Cardiac or proximal arterial emboli lodging in the posterior circulation[5] Associated with atrial fibrillation and valvular disease; embolism is recognised as the main infarction mechanism in symptomatic vertebrobasilar atherosclerosis[10]

Epidemiology

Vertebrobasilar or posterior circulation stroke accounts for approximately 20% of all ischaemic strokes[11]. Traditional stroke-related risk factors for VBI include male sex, diabetes mellitus, hypertension, and dyslipidaemia, with hypertension, obesity, and smoking considered the primary modifiable risk factors[12]. VBI is more frequently observed in men in the fourth decade of life[12].

Clinical Presentation

VBI classically presents with episodic symptoms that are transient and often provoked by positional changes, particularly cervical extension and rotation[13]. Dizziness, vertigo, headaches, vomiting, diplopia, blindness, ataxia, imbalance, and bilateral body weakness are among the most common symptoms[12]. Many manifestations of VBI may closely mimic non-vascular conditions, including labyrinthitis, vestibular neuritis, and benign paroxysmal positional vertigo (BPPV)[14]. The 5D's and 3N's represent the most consistently identified factors associated with cervical arterial dysfunction: Dizziness/Vertigo, Diplopia, Dysarthria, Dysphagia, Drop attacks, Nausea/Vomiting, Numbness and Nystagmus[15].

Evaluation

A baseline neurological screen should be performed prior to any cervical assessment in patients with suspected VBI, including cranial nerve examination, deep tendon reflexes, plantar responses, cerebellar function tests (finger-nose, heel-shin, Romberg), gait assessment, and upper and lower limb sensation[16].

Differential Diagnosis

Since Vertebrobasilar Insufficiency (VBI) resembles many conditions treated in physiotherapy, accurate diagnosis is crucial to ensure the right treatment approach; BPPV, Cervicogenic Dizziness, Vestibular Neuritis, Ménière's Disease, Orthostatic Hypotension and Multiple Sclerosis may resemble VBI[17].

Medical Management

Antiplatelet therapy forms first-line management for atherosclerotic VBI and non-cardioembolic posterior circulation TIA, in addition to aggressive reduction of modifiable risk factors including hypertension, diabetes, hypercholesterolaemia, and smoking[18]. Anticoagulation plays a key role in selected cases, particularly for cardioembolic aetiology and cervical artery dissection[19][18].

Physiotherapy Management

High-velocity low-amplitude (HVLA) cervical manipulation is absolutely contraindicated in confirmed or suspected VBI, active cervical artery dissection, and in the presence of any of the 5D's or 3N's during pre-intervention screening (International Framework for Examination of the Cervical Region)[20]. Cervical artery dissection is the most serious safety concern associated with cervical spinal manipulation, and the physiotherapist must exercise the highest level of caution and clinical reasoning in the cervical region[7].

Vestibular Rehabilitation

Where VBI has been medically managed and the patient has residual vestibular dysfunction, evidence-based vestibular rehabilitation is appropriate and well-supported[21]. Gaze stabilisation exercises produced significant improvements in gait, plantar pressure distribution, and balance function in post-stroke patients[22]. Canalith repositioning procedures are NOT appropriate for central vestibular pathology and must not be applied when a posterior circulation aetiology is suspected[21].

Falls Prevention and Gait Rehabilitation

Progressive balance training progressing from static to dynamic to dual-task conditions, functional gait rehabilitation, and home hazard assessment should be integrated into physiotherapy care following medical stabilisation[21][23].

Conclusion

Vertebrobasilar insufficiency represents a clinically significant vascular condition that physiotherapists must be equipped to recognise, screen for, and manage appropriately. The cornerstone of safe physiotherapy practice in the cervical region is systematic pre-intervention screening using the 5D’s and 3N’s within the International IFOMPT Cervical Framework. No single physical test confers adequate sensitivity to exclude vascular pathology; clinical reasoning, thorough risk factor assessment, and shared decision-making remain the most reliable safeguards. High-velocity thrust cervical intervention is absolutely contraindicated where VBI or cervical artery dissection is suspected.

References

  1. ↑ 1.0 1.1 Moors C, Stapleton C. Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: a systematic review. Journal of osteopathic medicine. 2025 Mar 28. https://www.degruyterbrill.com/document/doi/10.1515/jom-2024-0203/html?srsltid=AfmBOoqM-dmaLyjxWVMebgkMnYx4i9U1M76wcN9Mk3-N80JNoCg8kI_o
  2. ↑ Mehndiratta M, Pandey S, Nayak R, Alam A. Posterior circulation ischemic stroke—clinical characteristics, risk factors, and subtypes in a north Indian population: A prospective study. The Neurohospitalist. 2012 Apr;2(2):46-50.https://pmc.ncbi.nlm.nih.gov/articles/PMC3745183/
  3. ↑ Tudose RC, Rusu MC, Hostiuc S. The vertebral artery: a systematic review and a meta-analysis of the current literature. Diagnostics. 2023 Jun 12;13(12):2036.https://pmc.ncbi.nlm.nih.gov/articles/PMC10296927/
  4. ↑ Reyes-Soto G, Pérez-Cruz JC, Delgado-Reyes L, Castillo-Rangel C, Cacho Diaz B, Chmutin G, Nurmukhametov R, Sufianova G, Sufianov A, Nikolenko V, Sufianov R. The vertebrobasilar trunk and its anatomical variants: a microsurgical anatomical study. Diagnostics. 2024 Mar 2;14(5):534.https://pmc.ncbi.nlm.nih.gov/articles/PMC10930859/
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Neto AC, Bittar R, Gattas GS, Bor-Seng-Shu E, de Lima Oliveira M, da Costa Monsanto R, Bittar LF. Pathophysiology and diagnosis of vertebrobasilar insufficiency: a review of the literature. International archives of otorhinolaryngology. 2017 Jul;21(03):302-7.https://pubmed.ncbi.nlm.nih.gov/28680502/
  6. ↑ Blum CA, Yaghi S. Cervical artery dissection: a review of the epidemiology, pathophysiology, treatment, and outcome. Archives of neuroscience. 2015 Oct 17;2(4):e26670.https://pubmed.ncbi.nlm.nih.gov/26478890/
  7. ↑ 7.0 7.1 Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. European Spine Journal. 2023 Oct;32(10):3497-504.https://pubmed.ncbi.nlm.nih.gov/37422607/
  8. ↑ Ren Y, Chen H, Zhang C, Xie N. Anterior decompression of persistent vertebral artery occlusion caused by the cervical facet joint originated osteophyte. Orthopaedic Surgery. 2021 Dec;13(8):2468-71.https://pubmed.ncbi.nlm.nih.gov/34761541/
  9. ↑ Choi KD, Choi JH, Kim JS, Kim HJ, Kim MJ, Lee TH, Lee H, Moon IS, Oh HJ, Kim JI. Rotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke. 2013 Jul;44(7):1817-24.
  10. ↑ Hashimoto Y, Ikawa F, Kawano R, Hidaka T, Inoue Y, Yamamoto Y, Horie N. The Combination of Atrial Fibrillation and Occlusion Site Predicts In Situ Atherosclerotic Thrombosis in Basilar Artery Occlusion. Journal of Clinical Medicine. 2025 Sep 10;14(18):6384.https://pmc.ncbi.nlm.nih.gov/articles/PMC12471035/
  11. ↑ Schneider AM, Neuhaus AA, Hadley G, Balami JS, Harston GW, DeLuca GC, Buchan AM. Posterior circulation ischaemic stroke diagnosis and management. Clinical Medicine. 2023 May 1;23(3):219-27.https://pmc.ncbi.nlm.nih.gov/articles/PMC11046504/
  12. ↑ 12.0 12.1 12.2 Neto AC, Bittar R, Gattas GS, Bor-Seng-Shu E, de Lima Oliveira M, da Costa Monsanto R, Bittar LF. Pathophysiology and diagnosis of vertebrobasilar insufficiency: a review of the literature. International archives of otorhinolaryngology. 2017 Jul;21(03):302-7.https://www.thieme-connect.de/products/ejournals/html/10.1055/s-0036-1593448#jumpto-introduction
  13. ↑ Davis DD, Munakomi S, Kane SM. Rotational Vertebral Artery Syndrome. InStatPearls [Internet] 2024 Jul 3. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK559022/
  14. ↑ Heidenreich KD, Carender WJ, Heidenreich MJ, Telian SA. Strategies to distinguish benign paroxysmal positional vertigo from rotational vertebrobasilar ischemia. Annals of vascular surgery. 2010 May 1;24(4):553-e1.https://pubmed.ncbi.nlm.nih.gov/20116206/
  15. ↑ Myers BJ, Davey D, Cook CE. Factors associated with cervical arterial dysfunction: a survey of physical therapist educators in the United States. Journal of Manual & Manipulative Therapy. 2021 Jan 2;29(1):33-9.https://pmc.ncbi.nlm.nih.gov/articles/PMC7889238/
  16. ↑ Gross AR, Kay TM. Guidelines for pre-manipulative testing of the cervical spine-an appraisal. Australian Journal of Physiotherapy. 2001 Jan 1;47(3):166-7.https://pubmed.ncbi.nlm.nih.gov/26364251/
  17. ↑ Neto AC, Bittar R, Gattas GS, Bor-Seng-Shu E, de Lima Oliveira M, da Costa Monsanto R, Bittar LF. Pathophysiology and diagnosis of vertebrobasilar insufficiency: a review of the literature. International archives of otorhinolaryngology. 2017 Jul;21(03):302-7.https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0036-1593448
  18. ↑ 18.0 18.1 Savitz SI, Caplan LR. Vertebrobasilar disease. New England Journal of Medicine. 2005 Jun 23;352(25):2618-26.https://pubmed.ncbi.nlm.nih.gov/15972868/
  19. ↑ Tinone G, Hoshino M, Lucato L, Comerlatti LR. Anticoagulation and stroke. Arquivos de Neuro-psiquiatria. 2022 May;80(S 05):72-9.https://pmc.ncbi.nlm.nih.gov/articles/PMC9491440/
  20. ↑ Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: international IFOMPT cervical framework. journal of orthopaedic & sports physical therapy. 2023 Jan;53(1):7-22.https://pubmed.ncbi.nlm.nih.gov/36099171/
  21. ↑ 21.0 21.1 21.2 Meng L, Liang Q, Yuan J, Li S, Ge Y, Yang J, Tsang RC, Wei Q. Vestibular rehabilitation therapy on balance and gait in patients after stroke: a systematic review and meta-analysis. BMC medicine. 2023 Aug 25;21(1):322.https://pubmed.ncbi.nlm.nih.gov/37626339/
  22. ↑ Zhao R, Lu J, Xiao Y, Liu X, Wang Y, Xu G. Effects of gaze stabilization exercises on gait, plantar pressure, and balance function in post-stroke patients: a randomized controlled trial. Brain Sciences. 2022 Dec 9;12(12):1694.https://www.mdpi.com/2076-3425/12/12/1694
  23. ↑ Nairn B, Koohi N, Kaski D, Bamiou DE, Pavlou M. Impact of Vestibular Rehabilitation and Dual‐Task Training on Balance and Gait in Survivors of Stroke: A Systematic Review and Meta‐Analysis. Journal of the American Heart Association. 2025 Jun 3;14(11):e040663.https://www.ahajournals.org/doi/10.1161/JAHA.124.040663
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