Posterior circulation ischaemic stroke

Banerjee, Gargi; Stone, Sheldon; Werring, David J.

doi:10.1136/bmj.k1185

Cited by 29 publications

(29 citation statements)

References 24 publications

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“…Strokes in the vertebrobasilar territory are a diagnostic challenge because of the large number of clinical syndromes they can present with ( Table 2 ). 5 For example, brainstem ischaemia can lead to ‘crossed’ signs, while basilar ischaemia can result in bilateral hemiparesis, sensory loss, visual disturbance and ‘locked-in’ syndrome.…”

Section: Risk Factors For Strokementioning

confidence: 99%

Stroke: causes and clinical features

Murphy¹,

Werring²

2020

Medicine

246

100

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Stroke is a clinically defined syndrome of acute, focal neurological deficit attributed to vascular injury (infarction, haemorrhage) of the central nervous system. Stroke is the second leading cause of death and disability worldwide. Stroke is not a single disease but can be caused by a wide range of risk factors, disease processes and mechanisms. Hypertension is the most important modifiable risk factor for stroke, although its contribution differs for different subtypes. Most (85%) strokes are ischaemic, predominantly caused by small vessel arteriolosclerosis, cardioembolism and large artery atherothromboembolism. Ischaemic strokes in younger patients can result from a different spectrum of causes such as extracranial dissection. Approximately 15% of strokes worldwide are the result of intracerebral haemorrhage, which can be deep (basal ganglia, brainstem), cerebellar or lobar. Deep haemorrhages usually result from deep perforator (hypertensive) arteriopathy (arteriolosclerosis), while lobar haemorrhages are mainly caused by cerebral amyloid angiopathy or arteriolosclerosis. A minority (about 20%) of intracerebral haemorrhages are caused by macrovascular lesions (vascular malformations, aneurysms, cavernomas), venous sinus thrombosis or rarer causes; these are particularly important in young patients (<50 years). Knowledge of vascular and cerebral anatomy is important in localizing strokes and understanding their mechanisms. This guides rational acute management, investigation, and secondary prevention.

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Section: Risk Factors For Strokementioning

confidence: 99%

Stroke: causes and clinical features

Murphy¹,

Werring²

2020

Medicine

246

100

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“…For acute vestibular patients, Lee and Kim proposed that "isolated vascular vertigo is not indicated for thrombolysis due to its low disability score" and that "patients with AVS due to stroke should [only] be considered for intravenous thrombolysis or acute endovascular surgery when the NIHSS is > 4 or in cases with lower NIHSS that will clearly produce significant disability", whereas "conservative treatments […] may be sufficient for AVS in isolation or AVS associated with minimal disability such as internuclear ophthalmoplegia" [18]. However, the NIHSS is known to underestimate disability in PCS patients [2,37], and those presenting with a severe unsteadiness (or even inability) of stance and/or gait and maybe unilateral limb ataxia would still score less than 4 points on the NIHSS. This leads to the critical question whether a PCS presenting with an isolated AVS/AIS and only central oculomotor signs but no major focal neurological abnormalities produces "significant disability".…”

Section: Do Pcs Patients With Avs/ais Benefit From Ivt?mentioning

confidence: 99%

“…However, due to the sometimes unspecific clinical presentation and normal/low scores in the established stroke assessment scales (e.g., FAST-face arm speech test, NIHSS-National Institute of Health Stroke Scale) [2,33,37], PCS is three times more often missed than ACS in the acute stage [37]. Furthermore, PCS patients have longer median time from symptom onset to admission and are more likely to arrive at hospital beyond the 4.5 h time window [29], which can imply increased door-to-needle times [32] or a totally missed opportunity for IVT [17,28].…”

Section: Introductionmentioning

confidence: 99%

What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation?

et al. 2020

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Intravenous thrombolysis (IVT) is rarely performed in dizzy patients with acute vestibular syndrome (AVS) or acute imbalance (AIS) even if posterior circulation stroke (PCS) is suspected. Decision-making may be affected by uncertainties in discriminating central from peripheral vestibulopathy or concerns of IVT-related harm, particularly intracerebral hemorrhage (ICH), but related studies are missing. Using an in-house register of dizzy patients coming to the emergency room, we identified 29 AVS/AIS patients who presented within 4.5 h after onset, revealed clinical signs indicative of PCS (central oculomotor signs, mild focal abnormalities), and had non-contrast computed tomography (NCCT). Patients treated with IVT (n = 15) were compared to NoIVT patients (n = 14) with regard to clinical and imaging (including perfusion computed tomography, CTP) parameters, occurrence of ICH and short-term clinical outcome (NIHSS improvement; ability to walk independently). IVT and NoIVT patients did not differ in baseline characteristics, central oculomotor signs, or clinical outcome. IVT patients more often exhibited disabling vestibular symptoms (severe dizziness/vertigo, inability to stand unsupported) and focal abnormalities than NoIVT patients. There was no ICH in either group. CTP was performed in 0% of NoIVT versus 80% of IVT patients, seven of twelve revealing posterior circulation hypoperfusion. Comparison of initial hypoperfusion (CTP) and final stroke (NCCT) revealed IVT-related benefit (smaller lesion) in three of seven IVT patients. In AVS/AIS patients with suspected PCS, disabling vestibular symptoms, focal neurological deficits, and hypoperfusion on CTP seem to direct decision-making pro IVT. In our small cohort, there were no significant IVT-related clinical benefits, no IVT-related ICHs, and salvage of brain tissue in some patients.

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“…Posterior circulation strokes are misdiagnosed three times more often than anterior circulation strokes, as they frequently present with non-specific symptoms, including isolated ‘dizziness’ (vertigo or disequilibrium) or headache. 15 Acute onset vertigo or disequilibrium with an additional posterior circulation symptom should necessitate further assessment.…”

Section: Introductionmentioning

confidence: 99%

Diagnosis and management of acute ischaemic stroke

et al. 2020

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Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

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Posterior circulation ischaemic stroke

Cited by 29 publications

References 24 publications

Stroke: causes and clinical features

Stroke: causes and clinical features

What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation?

Diagnosis and management of acute ischaemic stroke

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