Title: Posterior Circulation Stroke
1Posterior Circulation Stroke
- Christopher Lewandowski, M.D.
- Sunitha Santhakumar, M.D.
- Henry Ford Hospital
- Detroit, Michigan
2Case 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
3Case 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
4Case 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
5What does this patient have?
- Differential Diagnosis
- Stroke
- Intracerebral Hemorrhage
- Tumor
- VBI
- Migraine
- Seizure
6Posterior 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
7Was 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
8Posterior Circulation Stroke Characteristics
- Clinical Findings
- The 5 Ds Dizziness, Diplopia, Dysarthria,
Dysphagia, Dystaxia - Hallmarks Crossed findings
- Cranial nerve deficits - Ipsilateral
- Motor / Sensory deficits - Contralateral
9Posterior Circulation Stroke Syndromes
10Posterior Circulation Stroke Anatomy
11Posterior Circulation Stroke Anatomy
12How 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
13Case Study CT Scan
14Case Study MRI - DWIlt12 Hours
4 Days
15Posterior 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
16Posterior 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
17Posterior 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
18Posterior 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
19Posterior 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
20Posterior Circulation Stroke Future Treatment
- Intra-arterial Thrombolysis
- Superselective approach, micro-catheters
- Angioplasty
- Angio-jet
21Case 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