Patterns of ischemic posterior circulation strokes: A clinical, anatomical, and radiological review

Abstract

Background Posterior circulation and anterior circulation strokes share many clinical, pathogenetic and radiological features, although some clinical signs are highly specific to posterior circulation strokes. Arterial stenosis and occlusions occur in significant numbers in both acute posterior circulation and anterior circulation strokes, making them good candidates for endovascular treatment. Among posterior circulation strokes, basilar artery occlusions stand out because of the diagnostic and acute treatment challenges. Methods We reviewed the literature on clinical stroke syndromes and neuroimaging findings and systematically describe for each anatomical site of stroke the detailed clinical and radiological information (anatomical representation, diffusion weighted imaging and angiographic sequences). The principles of neuroimaging of posterior circulation strokes and the prognosis for each stroke localization are also discussed. Review summary Stroke syndromes in the territories of the vertebral, basilar, cerebellar, and posterior cerebral arteries are presented. Features typical of posterior circulation strokes are highlighted, including patterns of basilar artery occlusions. Clinical severity and prognosis of posterior circulation strokes are highly variable, and given that they are more difficult to detect on CT-based neuroimaging, magnetic resonance imaging is the technique of choice in suspected posterior circulation strokes. Rapid identification of arterial occlusion patterns may provide prognostic information and support acute revascularization decisions. Conclusions Posterior circulation stroke syndromes tightly reflect lesion localization and arterial occlusion patterns. Although many clinical and pathogenetic features are similar to anterior circulation strokes, notable differences exist in terms of clinical presentation, stroke mechanism, prognosis, and response to acute recanalization.

Treatment of posterior circulation stroke: Acute management and secondary prevention

“… 1 One-fifth of strokes occur in the vertebrobasilar territory (also known as posterior) circulation. 2 Diagnosis of posterior circulation stroke and transient ischemic attack (TIA) can be more challenging than anterior circulation syndromes, and widely used screening protocols such as the face-arm-speech test (FAST) are less sensitive. 3 Optimal management of posterior circulation stroke, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation.…”

Anatomic and MRI Bases for Pontine Infarctions with Patients Presentation

“…PIs account for only about 7% of all IS according to radiologic studies, 1,2,7,8 and for 9% of all lacunar infarctions in a pathologic examination. 15 The main goal of this study was a comparison of the anatomic, radiologic and clinical data in these events.…”

“…3,4,18,21,24 Hemiparesis in a complete paramedian lesion of the lower pons is often associated with facial paresis, or supranuclear lingual or palatal palsy, including dysarthria and rarely dysphagia (damage to certain corticobulbar fascicles), ataxia (lesion of the pontine nuclei, and corticopontine or pontocerebellar fibers), vertigo (lesion of the pontocerebellar fibers or the vestibular nuclei), lemniscal signs, gaze disturbances (caused by a lesion of the horizontal gaze center and abducent nucleus), and internuclear ophthalmoplegia (lesion of the MLF). 3,8,21,23 Paramedian ischemia in the middle pons, where pyramidal bundles are not compact (Fig. 4B), can cause hemiparesis with arm predominance or brachial monoparesis, due to a lesion of the ventromedial pyramidal fascicles for hand and arm 18,25 Some supranuclear paresis also may appear.…”

Posterior circulation stroke from diagnosis to management, including recent data on thrombectomy for basilar artery occlusion from the BAOCHE and ATTENTION trials

“…A comprehensive review from Salerno and colleagues describes the clinical and corresponding anatomical features of PC stroke, and highlights specific syndromes. 1 It also covers optimal imaging approaches. It makes for a very useful clinical update.…”