Ischemic Posterior Circulation Stroke Christopher Lewandowski, M.D. Residency Program Director Department of Emergency Medicine Henry Ford Hospital, Detroit, MI Sunitha Santhakumar, M.D. Department of Emergency Medicine Henry Ford Hospital, - PowerPoint PPT Presentation

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Ischemic Posterior Circulation Stroke Christopher Lewandowski, M.D. Residency Program Director Department of Emergency Medicine Henry Ford Hospital, Detroit, MI Sunitha Santhakumar, M.D. Department of Emergency Medicine Henry Ford Hospital,

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Title: Ischemic Posterior Circulation Stroke Christopher Lewandowski, M.D. Residency Program Director Department of Emergency Medicine Henry Ford Hospital, Detroit, MI Sunitha Santhakumar, M.D. Department of Emergency Medicine Henry Ford Hospital,


1
Ischemic Posterior Circulation Stroke
Christopher Lewandowski, M.D. Residency Program
Director Department of Emergency Medicine Henry
Ford Hospital, Detroit, MI Sunitha Santhakumar,
M.D. Department of Emergency Medicine Henry
Ford Hospital, Detroit, MI
2
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.

3
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

4
Case Study
  • Physical Exam
  • BP- 149/79, P-100, RR-18, T-36.9
  • AOx3 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

5
Epidemiology
  • 20 of all strokes
  • The posterior circulation 20 of the CBF
  • Basilar artery occlusion 8 - 14 of posterior
    circulation strokes
  • Mortality 90 for BAO
  • 4 other posterior strokes
  • Unfavorable outcome 20-60

6
Posterior Circulation Stroke Anatomy
7
Posterior Circulation Stroke Anatomy
8
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

9
Posterior Circulation Stroke Prodrome
  • Prodrome very common
  • Occurs in 60 of patients with Basilar artery
    thrombosis
  • Common Prodomal Symptoms (in order of frequency)
  • Vertigo and Nausea (30)
  • Headache, Neckache (20)
  • Hemiparesis (10)
  • Dysarthria, Diplopia (10)
  • Hemianopia ( 6)
  • Ferbert, Stroke 1990

10
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
  • Horizontorotary Rare Common
  • Latency None 3-40 sec
  • Fatigue None yes

11
Posterior Circulation Stroke Syndromes
  • VBI, brainstem TIAs
  • Occur over days-weeks
  • Intermittent fluctuating brainstem sx
  • Dizziness plus cranial nerve symptoms
  • Rarely dizziness alone

12
Posterior Circulation Stroke Syndromes
13
Posterior Circulation Stroke Syndromes
  • Locked-in Syndrome
  • Basilar Artery or bilat. vertebral art. Occlusion
  • Progressive awake quadriplegia
  • Bilateral facial and oropharyngeal palsy
  • Preservation of cortical function and vertical
    gaze
  • Patient is awake and alert until RAS involved
  • gt90 in hospital mortality

14
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

15
Case Study CT Scan
16
Baseline CT scan
17
What is the prognosis for this patient ?
  • All Posterior Circulation Strokes
  • New England Medical Center Posterior Circulation
    Stroke Registry
  • Mortality 4
  • Minor or no Disability 79
  • Locked In Syndrome (Basilar artery occlusion)
  • Mortality gt 90
  • How do you know if a patient will progress to
    locked-in syndrome ? Observation

18
What are your treatment options?
  • Conservative Treatment
  • Antiplatelet and Antithrombotic
  • Thrombolytic Treatment
  • Intravenous within 3 hours symptom onset and
    the patient meets all treatment criteria
  • Intra-Arterial Therapy infusion of thrombolytic
    agent into vessel or clot within 24 hours of
    onset of symptoms

19
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 LMWH in acute stroke

20
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

21
Posterior Circulation Stroke Treatment
  • Intra-arterial Thrombolysis
  • 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

22
Posterior Circulation Stroke Future Treatment
  • Intra-arterial Thrombolysis
  • Superselective approach, micro-catheters
  • Angioplasty
  • Angio-jet

23
Case Study Outcome
  • The patient mental status deteriorated, repeat
    NIH-SS score was 22
  • He received intravenous thrombolysis
  • He had significant early improvement 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

24
Case Study MRI - DWI lt12 Hours
4 Days
25
Summary
  • Posterior Circulation Strokes are characterized
    by the 5Ds and crossed findings
  • Maintain a high index of suspicion for prodromal
    symptoms - vertigo with CN sx
  • The locked-in syndrome consists of quadriplegia,
    bilateral facial and oropharyngeal palsy but
    preservation of cortical function and vertical
    gaze

26
Summary
  • The prognosis for vertebrobasilar ischemia is
    generally good, except for locked-in syndrome
    (basilar artery occlusion)
  • Treatment consists of conservative therapy
    (aspirin and heparin) or IV thrombolysis (lt3 hrs)
    or IA thrombolysis (up to 24 hours)
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