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Posterior Circulation Stroke

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Posterior Circulation Stroke: Characteristics. Prodrome ... Center Posterior Circulation Stroke Registry: Mortality ... few posterior circulation strokes ... – PowerPoint PPT presentation

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Title: Posterior Circulation Stroke


1
Posterior Circulation Stroke
  • Christopher Lewandowski, M.D.
  • Sunitha Santhakumar, M.D.
  • Henry Ford Hospital
  • Detroit, Michigan

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
  • 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

5
What does this patient have?
  • Differential Diagnosis
  • Stroke
  • Intracerebral Hemorrhage
  • Tumor
  • VBI
  • Migraine
  • Seizure

6
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

7
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

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 Syndromes
10
Posterior Circulation Stroke Anatomy
11
Posterior Circulation Stroke Anatomy
12
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

13
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

16
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

17
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

18
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

19
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

20
Posterior Circulation Stroke Future Treatment
  • Intra-arterial Thrombolysis
  • Superselective approach, micro-catheters
  • Angioplasty
  • Angio-jet

21
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
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