Posterior Versus Anterior Circulation Infarction: How Different Are the Neurological Deficits?

Abstract

Conclusions: Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment for thoracic aortic aneurysms. TEVAR provides improved perioperative results and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysms initially decrease in diameter and then stabilize over time.Summary: Early clinical results with TEVAR have generally shown a trend toward better perioperative survival and less major perioperative complications than open thoracic aortic aneurysm repair. The early results of the pivotal trials used to gain approval of the Gore TAG, Medtronic Talent, and Cook Zenith TX2 stent grafts provided highly favorable midterm data for stent grafts. Longer-term data are still desirable, however. The authors investigated long-term survival and freedom from aortic complications in patients enrolled in five U.S. Food and Drug Administration investigational device exemption studies of TEVAR grafts from a single center and compared them with a group of open control patients with similar anatomic features. Demographic, clinical, and radiographic parameters were collected prospectively from patients enrolled in trials assessing the Gore TAG ( 55), Medtronic Talent (36), and Cook TX2 (15) devices. Outcomes in patients treated with these stent grafts were compared with 45 contemporaneous open controls. From 1995 to 2007, there were 106 patients enrolled in TEVAR trials at the hospital of the University of Pennsylvania and 45 open controls. TEVAR patients were older and had more comorbidities, including diabetes and renal failure. TEVAR patients had 2.3 Ϯ 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P ϭ .1) and paralysis/ paraparesis (3.9% TEAVR, 7.1% open; P ϭ .2) did not differ in the open vs TEVAR patients. Prolonged intubation Ͼ24 hours was more common in the open controls (9% TEVAR, 24% open; P ϭ .002). Overall survival at 8 to 10 years was ϳ40% and was similar between groups (log-rank P ϭ .5). Predictors of late mortality included age, diabetes, chronic renal failure, and chronic obstructive coronary disease. Use of TEVAR vs open surgery did not influence mortality (hazard ratio, 0.9; 95% confidence interval, 0.4-1.6). At 5 years in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention of the treated segment was 85% in TEVAR patients at 10 years.Comment: The article highlights the fact that compared with the number of patients in whom TEVAR has been performed, the number of patients with long term follow-up is still relatively small. (The University of Pennsylvania group has reported Ͼ500 TEVAR procedures in other articles.) In the discussion after the article, Dr Craig Miller from Stanford indicates that he is concerned that "the entire thoracic field is being 'dumbed down' as the TEVAR era evolved." One can easily extrapolate Dr Miller's concerned to all endovascular techniques "dumbing down" all of vascular surgery. In the long run, however, outcomes rather than nostalgia will drive practice patterns in the treatment of vascu...

Posterior circulation ischaemic stroke

“…The differences include the value of screening instruments, optimum diagnostic modalities, and clinical features (table⇓). [5][6][7][8][9] The face arm speech test (FAST), a widely used prehospital stroke recognition screening instrument, is less sensitive for detecting posterior circulation stroke than for anterior circulation stroke (the carotid territory, including the anterior and middle cerebral arteries and their branches). 5 It can be difficult to determine the vascular territory of an acute ischaemic clinical syndrome on purely clinical grounds, but this knowledge may be needed to determine the most appropriate acute treatment and prevention strategy.…”

“…Acute onset "crossed" deficits-cranial nerve territory symptoms on one side and sensory or motor deficits of the opposite arm and leg-are virtually diagnostic of posterior circulation ischaemia. 7 In a large single centre observational study of 407 patients, the most common posterior circulation symptoms were dizziness (47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%), and nausea or vomiting (27%). The most common signs were unilateral limb weakness (38%), gait ataxia (31%), unilateral limb ataxia (30%), dysarthria (28%), and nystagmus (24%).…”

“…However, all of these signs had a low sensitivity, ranging from 1.3% to 4.0%. 7 In practice it can be difficult to distinguish between posterior and anterior circulation stroke because some common syndromes (such as hemiparesis) are not specific for one or the other (table). 7 10 Vertigo (a feeling of true movement relative to the environment) and "dizziness" are common symptoms in general practice and the emergency room and present a particular challenge.…”

“…Resources for healthcare professionals Table Table 1| Comparison of anterior and posterior circulation ischaemic stroke [5][6][7][8][9] Posterior circulation (vertebrobasilar territory) Anterior circulation (carotid territory) Aspects Coma well recognised in thalamic and brainstem ischaemia and may be an acute presenting symptom Coma unusual, unless there is mass effect and raised intracranial pressure (for example, as a result of large middle cerebral artery stroke); rare as an initial hyperacute presenting symptom; somnolence may occur …”

Extracranial and Intracranial Ultrasonographic Findings in Posterior Circulation Infarction

“…Patients with posterior circulation infarction are at a higher risk of early recurrent stroke, especially those with vertebrobasilar stenosis or hypoplasia . However, the clinical presentations of posterior circulation infarction vary considerably, making diagnosis and treatment a challenge . Recognizing the vascular risk factors in these patients and arranging prompt treatment is of vital importance.…”