posterior circulation stroke treatment
Although they have been reported to have good long-term outcome, they are associated with a relatively high rate of perioperative morbidity, ranging up to 18%.142122. The patient noted immediate improvement in her symptoms after the procedure and has remained asymptomatic at 8 months of follow-up. Before discussing posterior circulation stroke syndromes, it is important to first understand the anatomy. Vascular access was obtained via a single-wall puncture of either the common femoral artery (n=19) or the ipsilateral brachial artery (n=2, patients 5 and 8). These results are congruent with those of others that have identified hypertension and smoking as the most common associated comorbid conditions.114 Although it is unclear whether the symptoms of vertebrobasilar territory ischemia are the result of thromboembolic events or whether they occur because of hypoperfusion,15 analysis of microemboli in the posterior circulation has revealed that the majority were the result of coexistent cardiac disease, with no correlation with disease of the vertebrobasilar system.16 This result suggests that the majority of non–cardiac-related posterior-circulation ischemia symptoms are related to hemodynamic impairment, in contrast to carotid disease, in which emboli are the major source of anterior-circulation strokes. Nine patients (42.8%) had simultaneous unilateral or bilateral carotid stenosis of >60%, and 3 had unilateral or bilateral carotid occlusion (14.3%). He was treated with aspirin but developed a stroke in the right occipital lobe 2 months later, which left a residual left lower quadrantanopia. Your last, or family, name, e.g. In that study, the majority of deaths were cardiac-related (52.5%) compared with stroke (20%). Explore the possibility of posterior circulation stroke in patients with new vertigo or disequilibrium, and those with new headache or changed migraine A negative HINTS examination in a patient with isolated vertigo can help rule out posterior circulation ischaemia The patient tolerated the procedure with no neurological deficits and was discharged on postprocedure day 4 on oral warfarin therapy. Table 3. Despite emergent angiography and superselective infusion of urokinase, the occlusion could not be recanalized. Web page addresses and e-mail addresses turn into links automatically. Diagnosis can be challenging; clinical presentation and common pitfalls facing posterior circulation stroke hav … Introduction: Patients presenting with acute ischemic stroke due to a large vessel occlusion of the anterior circulation (usually M1), are now offered thrombectomy after 6 major trials demonstrated superior results over IV tPA alone. His motor examination revealed weakness in both upper (4/5) and lower (4/5, proximal greater than distal) extremities. Figure 1. The patient underwent diagnostic angiography showing 65% stenosis of the left subclavian artery proximal to the origin of the left vertebral artery (Figure 8). With the microcatheter in this position, 250 000 U urokinase was administered over a period of 15 minutes. Accordingly, among the 8 patients treated who presented with subclavian steal, 4 had bilateral disease and 2 of the remaining 4 had developed an artery-to-artery embolus in the posterior circulation. This is an important characteristic, because the subclavian steal phenomenon in itself has previously been reported to be relatively benign and perhaps not to warrant aggressive surgical or interventional treatment when not symptomatic or not associated with hemodynamic spells.317, Although percutaneous balloon angioplasty alone has been used in the treatment of vertebral-origin stenosis, there has been increasing impetus to use intravascular stents because of the frequent observation of vessel recoil and restenosis after unsupported angioplasty,4 as illustrated in Figure 5 (compare Figure 5G and 5H). Diagnosis can be challenging; clinical presentation and common pitfalls facing posterior circulation stroke have been discussed elsewhere. Disclosure: Dr. Moussavi has nothing to disclose. Customer Service Contact Us, Correspondence and reprint requests to Adel M. Malek, MD, PhD, Department of Neurosurgery, Children’s Hospital, Bader 3, 300 Longwood Ave, Boston, MA 02115. The patient was placed on oral anticoagulant therapy but showed no improvement in symptoms after a period of 3 months. Figure 8. Although long-term angiographic follow-up will be needed to assess the durability of stent patency, the clinical outcome in this patient group, with a high proportion of contralateral and anterior-circulation disease, suggests a sustained benefit of the procedure. Herein I review how knowledge about the posterior circulation evolved. Ten of the patients (47.6%) presented with brain infarcts varying in age from subacute to acute, 9 of which were in the posterior-circulation territory. A 68-year-old man with coronary artery disease, 60 pack-years of smoking, and status post–radiation therapy for laryngeal carcinoma presents with orthostatic vertebrobasilar ischemia (patient 7). Posterior circulation strokes, including PCA strokes, may be underestimated by NIHSS when compared to anterior circulation strokes. Causes of posterior circulation ischemia include atherosclerosis, embolism, dissection, and dolichoectasia (elongation and … A 52-year-old right-handed man with diplopia, dysarthria, and left hemiparesis (patient 9). Methods: We conducted a comprehensive record review of patients who underwent acute endovascular intervention for posterior circulation ischemia at a community based, university affiliated comprehensive stroke center during a 5-year period (2010-2015). This is the first webinar in our series on posterior circulation strokes where the clinical history and presentation of acute ischemic stroke caused by basilar artery and vertebral artery occlusion is reviewed along with a discussion of imaging modalities useful for diagnosis and a review of populations most at risk of underdiagnosis of these types of strokes. Posterior circulation strokes represent approximately 20% of all ischemic strokes (1, 2). This finding is consistent with our data, because patients with coexisting carotid disease had a higher stroke rate than those with isolated vertebral artery disease. Patients were referred to our service for endovascular treatment and inclusion after having undergone negative studies for a cardiac embolic source and after having failed oral anticoagulant or antiplatelet therapy. Recanalization rate according to modified Treatment in Cerebral Ischemia score and neurological outcome at three months according to modified Rankin Scale were the main outcomes. A 53-year-old right-handed man with hypertension, hyperlipidemia, and status post C4-5 and C5-6 cervical fusion presented 14 months before admission with transient ischemic episodes consisting of visual field deficits. In contrast to the anterior circulation, several differences in presenting symptoms, clinical evaluation, diagnostic testing, and management strategy exist presenting a challenge to the treating physician. Schematic of the aortic arch with bilateral subclavian and vertebral arteries (carotid arteries are cut off proximally) in the 21 patients. Abstract. A guide catheter (Brite Tip, Cordis) was then carefully placed into the aortic arch or innominate artery for treatment of the proximal left or right subclavian lesions or in the subclavian artery proximal to the vertebral artery origin. The patient was given a weight-adjust… Embolism is the most common stroke mechanism in posterior circulation. If identified within the window for thrombolysis, thrombolysis for posterior circulation strokes was found to have no worsened risks and similar benefits as compared to patients who received thrombolysis for anterior circulation ischemic events (Forster et al., 2011) Summary of Clinical Outcome, Immediately Postprocedure, at 30 Months and at Latest Follow-Up. © American Heart Association, Inc. All rights reserved. The role of modern endovascular treatment has been extensively studied for anterior circulation strokes, leading to clear guidelines outlining the management in this patient group. Conclusion: The benefits of thrombectomy for posterior circulation strokes compare well with those recently achieved by the trials evaluating the treatment for anterior circulation strokes. The location of the stenotic lesions treated in this cohort was as follows: 10 lesions (47.6%) at the origin of the vertebral artery, 3 (14.3%) at the midcervical vertebral artery, and 8 (38%) in the subclavian artery proximal to the vertebral artery origin. A balloon angioplasty catheter (4×20 mm Powerflex, Cordis) was used to dilate the origin, with an inflation of 13 atm of pressure. All 6 of these patients had resolution of the angiographic steal syndrome by the stent and angioplasty procedure (100%). organization. h−1. Determine when to triage posterior circulation stroke patients to ICU, neuro-stepdown or floor. This includes your brain stem, cerebellum (the area responsible for balance and coordination) and occiptal lobes (the area responsible for vision). The difference in proportion of group 4 patients between our study and the NEMC is undoubtedly the result of selection bias. Your organization or institution (if applicable), e.g. Introduction. The treatment approach to stroke is determined by localizing the problem (identifying the... Tissue Plasminogen Activator. A posterior circulation ischemic stroke is defined as an infarct occurring in the vascular territory supplied by the vertebrobasilar system. Neurological outcome immediately after the procedure, at 30 days, and at latest follow-up (mean, 20.7 months) as defined in Methods. An MR scan revealed a left pontine infarct. We report our endovascular treatment strategy for posterior circulation tandem occlusion. At long-term follow-up, 68% of patients were asymptomatic, compared with 57% in our group. https://doi.org/10.1161/01.STR.30.10.2073, National Center Introduction: Patients presenting with acute ischemic stroke due to a large vessel occlusion of the anterior circulation (usually M1), are now offered thrombectomy after 6 major trials demonstrated superior results over IV tPA alone. The initial NIHSS, discharge NIHSS and discharge mRS were abstracted. Submit only on articles published within the last 8 weeks. A vascular ultrasound of the cervical vessels disclosed the finding of bidirectional flow in the left vertebral artery consistent with left subclavian steal syndrome. Mean change in NIHSS was 4 (SD =6). Stenoses, occlusions, and dissections of the arteries are represented. You are working the night shift in the ED, and you see the next patient is a 38-year-old female complaining of dizziness. The patients then underwent the procedure either under monitored anesthesia care with short-acting intravenous sedation or under general endotracheal anesthesia. Twenty percent of ischemic events in the brain involve the posterior circulation. Digital subtraction angiography (anteroposterior projection) of the left subclavian artery shows a hemodynamically significant stenosis (65%) (arrow) proximal to the origin of the left vertebral artery (A). Reference 1 must be the article on which you are commenting. The right vertebral artery was irregular in contour, and the left showed a 1-cm segment of irregular caliber at its origin and a more distal stenosis. I was fortunate to have been mentored by some of the individuals who have made key contributions during the second half of the 20th century. Introduction: Patients presenting with acute ischemic stroke due to a large vessel occlusion of the anterior circulation (usually M1), are now offered thrombectomy after 6 major trials demonstrated superior results over IV tPA alone. The distribution of the posterior-circulation infarcts wasas follows: occipital lobe 58.3%, pontine 25%, and cerebellar 16.7%. Repeat angiography at the time of the procedure reveals complete occlusion of the left vertebral artery (lower arrow) with distal reconstitution at the C4 vertebral level via muscular branches of the thyrocervical trunk (upper arrow) (D) and only faint filling of the posterior circulation (E). A microguidewire and catheter were used to cross the left vertebral artery stenosis, which underwent balloon dilatation of the proximal and distal stenoses. The evaluation and management of acute ischemic stroke (including stroke involving the posterior circulation) are discussed separately. 1-800-AHA-USA-1 Changes that may occur include the following. Statistical significance was assumed for a value of P<0.05. Intimal dissection resulting from angioplasty was encountered in 7 procedures, 5 of which were treated by additional stent deployment; 2 cases (patients 12 and 18) in which the dissection was minimal and not flow-limiting had no further treatment. Local Info The patient was placed on warfarin after MR angiography, and a conventional angiogram disclosed the presence of a highly stenotic and irregular lesion in the proximal left vertebral artery origin (Figure 7). One patient with a known severe, left cavernous internal carotid artery stenosis (>95%) (patient 8) underwent successful stent placement in the left subclavian and vertebral arteries with an uneventful immediate postprocedural course but developed acute thrombotic occlusion of the left internal carotid artery. Peripheral Causes of Vertigo Posterior circulation strokes account for approximately 20% of all strokes, but posterior circulation emergent large vessel occlusions (pc-ELVO) are rare, representing only 1% of all ischemic strokes, and 5% of all ELVOs.1–3 These strokes are often devastating events. Background and purpose: Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. Dr. Kirmani has nothing to disclose. NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. Of those 310 were posterior circulation strokes; of which, 34 underwent endovascular treatment. Ataxia Repeat angiography 7 months later revealed worsening in the stenosis and irregularity of the left vertebral artery origin. There was 1 TIA within 24 hours of the procedure (patient 12). Copyright © 2016 by AAN Enterprises, Inc. Stay timely. 2016. NOTE: The first author must also be the corresponding author of the comment. LICA indicates left internal carotid artery; LSCA, left subclavian artery. higgs-boson@gmail.com. The patient was maintained on heparin, was converted to warfarin, and was able to ambulate on his own on postprocedure day 3. (See "Initial assessment and management of acute stroke" and "Approach to reperfusion therapy for acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack".) Dr. Brar has nothing to disclose. May have additional signs of of Posterior Circulation Stroke- 5Ds: Dizziness , Dysarthria, Dystaxia, Diplopia, Dysphagia; Can be confused with acute vestibular syndrome (e.g. Identify patients with posterior circulation stroke. … Axial T2-weighted MR study performed 2 months before procedure reveals increased signal focus in the left pons consistent with infarct (A). Dallas, TX 75231 Read any comments already posted on the article prior to submission. Your email address, e.g. Postdeployment angiography of the left subclavian artery shows reestablishment of the native vessel caliber (C). This vessel had been patent though stenotic in the angiogram performed 2 months before admission. Distribution of patients at presentation based on the Wityk classification1 for extracranial proximal vertebral stenosis. An ambulatory EEG was negative, but a Holter monitor showed a 9-second pause, for which the patient underwent placement of a VDD pacemaker. On examination, he was dysarthric and had a right-sided internuclear ophthalmoplegia and decreased sensation in the left V2 distribution with flattening of the left nasolabial fold. These were compared with 1,386 patients with proximal anterior circulation strokes included in the recent MPRCTs. She has never had any previous episodes of dizziness. The majority of patients (20 of 21, 95.2%) were symptomatic and experienced either improvement in their posterior-circulation symptoms or no further episodes of ischemia after the procedure, except for 1 patient who developed a transient arm weakness that resolved within 24 hours (1 of 21, 4.8%) (Figure 4). Injection of the left subclavian artery now showed filling of the bilateral anterior cerebral arteries from the left vertebral artery via a patent left posterior communicating artery (Figure 6G). Ultrasound follow-up at 24 months confirms anterograde flow in the left cervical vertebral artery. Arrows point to the treated lesion site in each case. Twelve patients had a significant smoking history of >30 pack-years (57.1%). Purpose: Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. The ACT was obtained after initial heparin bolus to ensure a value greater than twice baseline ACT, or >250 seconds. The patients were placed on an oral regimen of ticlopidine (250 mg PO BID) or clopidogrel (75 mg PO QD) for 6 weeks and on indefinite aspirin (325 mg PO QD). Demographic Characteristics of Patients, Clinical Presentation, Lesion Site, History of Previous Infarct, Coexisting Medical Problems, Status of Contralateral Vertebral and Subclavian Arteries, and Extent of Anterior-Circulation Disease, Table 2. Only 13.8% of lesions in that series were bilateral, compared with 76.2% in our patient population. A 52-year-old right-handed man with coronary artery disease and previous radiation therapy for a mediastinal tumor developed a stroke after noting sudden diplopia, left leg weakness, and dysarthric speech. A 7F to 9F access sheath was used (Avanti, Cordis Endovascular Systems). The paucity of collateral flow in the patient population treated in the present study is underlined by the extent of bilateral vertebral or subclavian stenosis or occlusion and anterior-circulation disease. Blood flow to the brain must be restored as quickly as possible. The procedure-related mortality was 4.8%, and morbidity was 9.5% (Table 3). This occurred in a patient with obliterative vasculopathy and concomitant occlusion of the left internal carotid artery, contralateral subclavian artery, and bilateral common femoral artery stenoses. These attacks were different from the ones noted before the procedure because of their orthostatic independence. Given the lack of response to medical therapy and the extensive carotid occlusive disease, a decision was made to treat the vertebral artery stenosis. Unauthorized Assessment of symptom-free status (neurological score=1) revealed it to be inversely correlated with contralateral disease (χ2=6.3, P<0.012), carotid occlusion (χ2=4.7, P<0.03), and anterior-circulation atherosclerosis (χ2=7.8, P<0.005). Arterial ischemic stroke (AIS) occurs in ≈1.7 to 3 per 100 000 children per year and is an important cause of childhood morbidity. A microguidewire and catheter were navigated into the very proximal left vertebral artery, where a small test injection confirmed intraluminal placement without intimal dissection. A baseline angiographic study was performed of the bilateral subclavian, vertebral, and carotid arteries to determine the extent of vascular disease and presence of collateral circulation. In their analysis, Wityk et al found that group 4 patients constituted 16% of registry patients and had the highest proportion (92%) of bilateral vertebral artery abnormalities. A 7F guide catheter was placed in the left subclavian artery, and an AVE stent (GFX 4×18 mm) was positioned primarily across the lesion and deployed by balloon inflation to 9 atm (Figure 6). Posterior circulation strokes, including PCA strokes, may be underestimated by NIHSS when compared to anterior circulation strokes. The third complication (patient 5) resulted from mild thrombocytopenia (platelet count of 68 000/mm3) after discharge from the hospital, which resolved with discontinuation of ticlopidine. Your role and/or occupation, e.g. Three days later, he had another episode of diplopia with worsening speech and left hemiparesis despite therapeutic anticoagulation. Extracranial disease of the vertebral and subclavian arteries is difficult to diagnose and monitor with noninvasive techniques and has been less well defined than carotid vascular disease.1212 Moufarrij et al,13 in their study of 96 patients with >50% stenosis, found the 5-year survival rate to be 27% lower than in a control population. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Late-venous-phase DSA of the left subclavian artery reveals retrograde contrast pooling within 1 cm of the cranial edge of the left subclavian artery (arrowheads) (F), confirming persistent patency of the proximal left vertebral artery beyond the occluded origin. According to the classification of V1 vertebral proximal stenosis of Wityk et al,1 1 patient was in group 1, with intracranial high-grade stenosis; 4 patients were in group 2, with evidence of artery-to-artery embolus; 14 patients were in group 4, with transient ischemic attacks (TIAs) suggestive of hemodynamic spells involving the posterior circulation; and 2 patients were in group 5, with vertebral dissection (Figure 1). However, there are few trials evaluating the benefit of clot retrieval in posterior circulation strokes. 1–4 Childhood AIS mainly occurs in the anterior circulation, 5 whereas only 15% to 22% of cases occur in the posterior circulation. Eighteen of the 21 patients (85.7%) had hypertension, 7 (33.3%) had hypercholesterolemia, 6 (28.6%) had coronary artery disease, and 4 (19%) had diabetes mellitus (Table 1). Stroke is a leading cause of disability in the United States (1,4-6). Background: Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischemic stroke (ACIS) and posterior circulation ischemic stroke (PCIS). Digital subtraction angiography of the left subclavian artery demonstrates an irregular long-segment high-grade stenosis extending 2 to 3 cm from the origin of the left vertebral artery cranially (delimited by arrows) (C). Thus, our data confirm the evidence for an aggressive target time metric in endovascular therapy for posterior circulation stroke patients, as reported in anterior circulation large‐vessel strokes. Embolism is the most common stroke mechanism in posterior circulation.