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    What does this CT scan report indicate?

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Posted on Fri, 4 Aug 2017 in Headache and Migraines
Question: Here is my last question for this service. It's my last idea. I have been having headaches, dizziness, facial numbness with the only possible cause according to my doctor being migraine. The last idea I have is maybe I have a vetrbral artery insufficiency. I was apparently born with a very small right vetrbral artery. I know this can be considered a common varient but lately I have been reading that in adulthood in can cause my exact symptoms... headaches dizziness and numbness. please see attached 2 page ct report (from years ago) could this be a possibility
I know one can make up FOR the other but still could this be an idea? report attached
doctor
Answered by Dr. Olsi Taka 2 hours later
Brief Answer:
Unlikely but possible.

Detailed Answer:
I read your question carefully and I do see your point, it would be a sensible hypothesis.

As you yourself say it is a very common finding, figures vary but about 10% of people or more have such an asymmetry, in particular with the right vertebral artery as in your case. Normally that shouldn't constitute a problem, the other vessels compensate, as the report says you have a "dominant and robust" left vertebral artery which should compensate well enough. The fact that it is a born issue reinforces that as it has been present since birth without any previous problems.

That being said when no other cause is found it is a possibility to be considered. In certain situations say dehydration and low blood pressure, there may be low perfusion which can manifest with some of those symptoms you mentioned. Actually even when it comes to vestibular migraine there are studies showing a higher frequency of migraine in patients with vertebral artery hypoplasia (small vertebral artery). That could not be solely related to the perfusion but also to altered vasomotor activity, activity of the autonomous nervous system, which is involved in migrane.

Unfortunately there is no way to verify that, to measure blood perfusion in given periods of time. Migraine pathogenesis itself is still unclear. So these are only hypotheses for now. From a practical point of view there is not much that can be done anyway, even if that was the cause, apart from avoiding dehydration and other low blood pressure inducing situations.

I remain at your disposal for other questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka 28 minutes later
What about the right PICA? For example in my case the right PICA is hardly even visualized which is supplied by the right VA.

Say for example someone with a small R VA, ended up having a total occlusion, how would the R PICA get blood flow? and how could they even fix that in someone who had a blockage in the right VA causing blood not being able to get the to PICA? Yes I understand how a larger left VA can still provide enough blood to the basilar artery, but what about the PICA?

Also in the case the that PICA was not getting enough blood aka a stroke, a mri would show this correct? (as in tissue damage in that area) What I really am asking is if my Diffusion weighted mri images are normal, then stroke would be eliminated correct?

Also is there really a way to look for overall basial artery and or pica insufficiency?
doctor
Answered by Dr. Olsi Taka 1 hour later
Brief Answer:
Read below.

Detailed Answer:
Actually when I spoke of the low flow in my answer what I had in mind was precisely PICA. The territory supplied by it would be the most likely to suffer from lack of blood flow, that is the most important branch of the vertebral artery, when it comes to the basilar there are no concern, not with that dominant vertebral artery.
How does PICA get its supply... partly it is through that vertebral artery small as it may be. Furthermore if the pressure drops there would also be retrograde flow from the basilar artery. In addition to that there are also the anastomoses between the cerebellar arteries, in fact the PICA has anastomoses with the other cerebellar arteries the SCA and AICA. When it doesn't get enough blood flow from its stem these small anastomoses better develop over time, getting blood from these other vessels.

If the blood supply was reduced enough in quantity and time duration to cause a stroke it would show on MRI, that is correct, if there was damage it would be well visible, initially on DWI (diffusion weighted imaging) and some hours later on FLAIR and other sequences as well. So a normal MRI excludes stroke.

Regarding the last question as I already said in my previous answer, the answer is no, there is no way to verify that. Even if an estimation is provided by MRI and CT, or also through Doppler ultrasound, still they can't evaluate what happens in all situations, when changing position, when dehydrated or with low blood pressure, circulation is dynamic, not static over time.

Let me know if I can further assist you.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka 39 minutes later
Ok my last question. Are vetrebral and pica arteries prone to plaque build up or not so much for these arteries ? the reason I ask is someone who has really small arteries like this on one side seems like they would be more prone to have blockage from clot break off from other parts of the body.

also as far as clot break off is this a common place where they could end up or not really?

and then to summarize I guess as long as someone has a normal MRI thats showing that that part of their brain is getting adequate blood flow (via normal scan) for the tissue to survive there is no issue or danager correct?

and as far as a possible insufficiency thats not possible to test for.... but I guess if it's congenital it's very unlikely as a lot of the population has this and does not have symptoms. I read that almost 15% of people have one side of pica that is super small and some even have a total absence.

correct ?

Thanks
doctor
Answered by Dr. Olsi Taka 3 hours later
Brief Answer:
Read below.

Detailed Answer:
Vertebral arteries are less prone to atherosclerotic plaque build up. There is a slightly increased risk for plaque formation when the arteries are very narrow though. As for receiving clots from other parts of the body the likelihood is lower then for the big arteries of the anterior circulation, not a common place.

Yes a normal MRI indicates there is no damage to that part of the brain. The percentage of this anomaly is very high, ranges from 10-25% of the population (varies among studies) but the other vessels adapt and compensate. It is true that in some cases there is no PICA at all, but other vessels have taken charge of blood supply in that territories.

So to conclude again, brain vascular anatomy is very variable among different people, but doesn't mean you are not getting enough blood, remember that you were born like that and have done just fine for decades. Yes it's true there is a slightly increased risk of plaques, but that isn't the cause of your symptoms (would show on imaging) and is not something which you should worry at your age of 33, plaques cause problems much later, decades later. So just lead a healthy lifestyle in order to prevent their build up over the decades, it is not a current issue.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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