New England Medical Center Posterior Circulation Stroke Registry II. Vascular Lesions

Abstract

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, the extracranial (ECVA) and intracranial vertebral arteries (ICVA) were the commonest sites of severe occlusive disease followed by the basilar artery (BA). Severe occlusive lesions were found in >1 large artery in 148 patients; 134 had unilateral or bilateral severe disease at one arterial location. Single arterial site occlusive disease occurred most often in the ECVA (52 patients, 15 bilateral) followed by the ICVA (40 patients, 12 bilateral) and the BA (46 patients). Involvement of the ICVAs and the BA was very common and some patients also had ECVA lesions. Hypertension, smoking, and coronary and peripheral vascular disease were most prevalent in patients with extracranial disease while diabetes and hyperlipidemia were more common when occlusive lesions were only intracranial. Intra-arterial embolism was the most common mechanism of brain infarction in patients with ECVA and ICVA occlusive disease. ICVA occlusive lesions infrequently caused infarction limited to the proximal territory (medulla and posterior inferior cerebellum). BA lesions most often caused infarcts limited to the middle posterior circulation territory (pons and anterior inferior cerebellum). Posterior cerebral artery occlusive lesions were predominantly embolic. Penetrating artery disease caused mostly pontine and thalamic infarcts. Prognosis was poorest in patients with BA disease. The best prognosis surprisingly was in patients who had multiple arterial occlusive lesions; they often had position-sensitive transient ischemic attacks during months or years.

Clinical profile and prognosis of patients with posterior circulation stroke

“…This was comparable with study by Caplan et al where hypertension was risk factor in 61% patients. 15 Other risk factors found by them were tobacco abuse (35%), diabetes (25%) and dyslipidaemia (25%). Kora et al found most common risk factor for posterior circulation stroke as tobacco abuse 52% and hypertension as the second common risk factor (37%).…”

Clinical Characteristics and Outcome in the Acute Phase of Ischemic Locked-In Syndrome: Case Series of Twenty Patients with Ischemic LIS

“…Various transitory premonitory neurological symptoms, mainly from dysfunction of vestibulocerebellar (dizziness and vertigo) or motor/oculomotor brain stem structures (dysarthria), were reported in 79% of our patients and a slightly lower frequency (64%) was also noted in the group of patients with severe bilateral ICVA occlusive disease [15]. The majority of our subjects had documented or self-reported vertebrobasilar TIAs in the last 36 h preceding stroke, but this could be to some extent the result of recall bias.…”

“…Nonetheless, Patterson and Grabois [3] reported that the majority of patients with ischemic LIS also had TIAs during the day prior to the onset of stroke. The data from NEMC-PCR study show that the average period of time during which TIAs occurred in patients with bilateral pontine infarctions due to BA thrombosis is much shorter than in those with extensive posterior circulation disease (mean 2.1 vs. 7.8 months) [15]. This narrow time window, between multifocal vertebrobasilar TIAs and an impending acute BA occlusion possibly resulting in a locked-in state, highlights the need for urgent neurovascular evaluation in patients with clinical signs of severe BA occlusive disease [16].…”

Stroke Classification

“…[17][18][19] Outcomes also could be analyzed in relation to brain location, vascular lesions, and stroke mechanisms. 20 Because designation of stroke mechanism was controversial in the Harvard Stroke Registry and the Stroke Data Bank, we chose a different strategy in the NEMC-PCR.…”