Posterior Circulation Stroke

1
Posterior Circulation Stroke

• Christopher Lewandowski, M.D.
• Sunitha Santhakumar, M.D.
• Henry Ford Hospital
• Detroit, Michigan

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Case Study

• HPI
• The patient is 41 y.o. male, with a past history
  of alcohol abuse, hypertension who presents to
  the ED with a chief complaint of right -sided
  weakness, slurred speech, and loss of balance.
  The symptoms began 90 minutes prior to arrival

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Case Study

• PMHx
• Alcohol Abuse, quit for 3 years
• Hypertension
• Seizures, Generalized, none for past 7 years
• Medications
• Dyazide
• Social Hx
• Smoking- 2 pack per day
• ROS Mild dizzy spells for the past 2 weeks,
  each lasting 5-10 minutes

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Case Study

• Physical Exam BP- 149/79, P-100, RR-18, T-36.9
• A Ox3 on presentation, later became stuporous
• CN dysarthria, pupils R 3.5/ L 3.0 reactive
• L facial droop, gaze palsy to the L
• Motor R arm and R leg weakness (3/5)
• Sensory Decreased to light touch and pinprick on
  R
• Coordination dysmetria on R (not out of
  proportion to weakness)
• NIH Stroke Scale score 14

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What does this patient have?

• Differential Diagnosis
• Stroke
• Intracerebral Hemorrhage
• Tumor
• VBI
• Migraine
• Seizure

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Posterior Circulation Stroke Characteristics

• Prodrome
• Occurs in about 60 of patients with Basilar
  artery thrombosis
• Common Prodromal Symptoms (in order of
  frequency)
• Vertigo and Nausea (30)
• Headache, Neckache (20)
• Hemiparesis (10)
• Dysarthria, Diplopia (10)
• Hemianopia (6)
• Ferbert, Stroke 1990

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Was this Patients Dizziness Central or Peripheral

• Central Peripheral
• Intensity Mild Severe
• Tinnitis Rare Common
• CN findings Frequent None
• Nystagmus
• Visual fixation No inhibition Inhibits
• Purely horiz. Common Rare
• Latency None 3-40 sec
• Fatigue None yes

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Posterior Circulation Stroke Characteristics

• Clinical Findings
• The 5 Ds Dizziness, Diplopia, Dysarthria,
  Dysphagia, Dystaxia
• Hallmarks Crossed findings
• Cranial nerve deficits - Ipsilateral
• Motor / Sensory deficits - Contralateral

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Posterior Circulation Stroke Syndromes
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Posterior Circulation Stroke Anatomy
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Posterior Circulation Stroke Anatomy
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How do you evaluate this patient

• Confirm the Diagnosis (Emergent)
• CT Scan
• MRI
• Blood Studies
• Evaluation of Stroke Etiology (Inpatient)
• MRA / Angiography
• Echo / TEE
• TCD
• Carotid Doppler

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Case Study CT Scan
14
Case Study MRI - DWIlt12 Hours
4 Days
15
Posterior Circulation Stroke Prognosis

• All Posterior Circulation Strokes
• New England Medical Center Posterior Circulation
  Stroke Registry
• Mortality 4
• Minor or no Disability 79
• Locked In Syndrome
• Mortality gt 90

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Posterior Circulation Stroke Treatment

• Conservative Treatment
• Antiplatelet and Antithrombotic
• Thrombolytic Treatment
• Intravenous if the patient presents within 3
  hours symptom onset and meets all treatment
  criteria
• Intra-Arterial Therapy local infusion of
  thrombolytic agent into vessel or clot

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Posterior Circulation Stroke Treatment

• Conservative Treatment
• Antiplatelet and Anti thrombotic Therapy
• Uncontrolled, Retrospective Studies , 1950s
  1960s
• Compared to historical controls, patients treated
  with heparin had lower mortality (8-15 vs.
  40-60)
• Stopped progression of VBI to infarction
• TOAST Trial
• No evidence to support heparinization in acute
  stroke

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Posterior Circulation Stroke Treatment

• Intravenous Thrombolysis
• NINDS rt-PA Acute Stroke Trial
• t-PA approved within 3 hours of symptom onset
• few posterior circulation strokes
• How do you know if a patient will progress to
  locked-in syndrome

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Posterior Circulation Stroke Treatment

• Intra-arterial Thrombolysis, Local
• No randomized controlled trials completed
• Multiple small series and reports
• Results (Over 200 patients treated)
• Mortality 20-60 , assoc. with lack of
  recanalization
• Favorable outcomes in 25-60
• ICH rate low, 0-15

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Posterior Circulation Stroke Future Treatment

• Intra-arterial Thrombolysis
• Superselective approach, micro-catheters
• Angioplasty
• Angio-jet

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Case Study Outcome

• The patient received intravenous thrombolysis
  after his mental status deteriorated with a
  NIH-SS score of 22
• He improved initially, but without complete
  resolution of symptoms
• On day 4, the NIH - SS score was 10
• MRA L sup. cerebellar art. and RL Ant-Inf
  cerebellar arteries were non-visualized,
• Cardiac evaluation was negative
• He was discharged on Coumadin to Rehab