posterior circulation stroke treatment
In that study, the majority of deaths were cardiac-related (52.5%) compared with stroke (20%). Table 1. Dr. Kirmani has nothing to disclose. 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. Intravenous thrombolysis is effective treatment for acute ischaemic posterior circulation stroke 25 26 27 if given within 4.5 hours of symptom onset. (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".) Graph of pretreatment and posttreatment stenosis of vertebral and subclavian stenosis determined from the digital subtraction angiograms by the NASCET method.11. Submitted comments are subject to editing and editor review prior to posting. Injection of the right subclavian artery reveals slight to moderate focal disease with filling of the right vertebral artery (arrows) (D). 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). 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. 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. This includes your brain stem, cerebellum (the area responsible for balance and coordination) and occiptal lobes (the area responsible for vision). Our goal was to evaluate the benefit of thrombectomy for posterior circulation strokes. The treatment approach to stroke is determined by localizing the problem (identifying the... Tissue Plasminogen Activator. Embolism is the most common stroke mechanism in posterior circulation. Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB), Journal of the American Heart Association (JAHA), Customer Service and Ordering Information, Basic, Translational, and Clinical Research, Focused Updates in Cerebrovascular Disease, Treatment of Posterior Circulation Ischemia With Extracranial Percutaneous Balloon Angioplasty and Stent Placement, Episodic VBI, blindness, loss of consciousness, Orthostatic VBI, lightheadedness, dizziness, HTN, smoking, renal insufficiency, AAA, anemia, Right PCA infarct with residual quadriparesis 1 mo before admission, Bilateral internal capsule, left occipital lobe, Occluded left VA origin, distal RVA stenosis (80%), Episodic VBI, nausea, vomiting, intermittent quadriparesis, Midbasilar stenosis, occluded distal tandem right VA, Bilateral cerebellar and occipital infarcts, HTN, CAD, AAA, smoking, HChol, renal insufficiency, Episodic VBI, vertigo, dizziness, dysarthria, Orthostatic VBI, dizziness, visual changes, transient hemiparesis, CAD, smoking, laryngeal CA, radiation therapy, Orthostatic VBI, dizziness, visual changes, staggering gait, LSCA and LVA stenosis with subclavian steal, Residual diplopia, dysarthria, left leg weakness, LVA thrombotic occlusion/stenosis/ thrombolysis of occluded LVA, CAD, HTN, smoking, lung CA, radiation therapy, Subclavian steal, dizziness, abnormal gait, HTN, HChol, obliterative arteriopathy, basilar aneurysm, s/p GDC coiling, Episodic VBI, dizziness, acute visual field deficit, Right cerebellar bilateral occipital infarcts, Subacute right PICA occlusion, chronic LVA dissection with flap and pseudoaneurysm on coumarin, Episodic VBI, sudden loss of consciousness and fall, Episodic VBI, vertigo, dizziness, diplopia, left arm claudication, CAD, HTN, smoking, PVD, HChol, s/p aortobifemoral BG, s/p L CCA-SCA BG, HTN, smoking, hypothyroidism, PVD, prior right CEA, CAD, HTN, smoking, hypothyroidism, s/p MI, Episodic VBI, dizziness, vertigo, bilateral hand numbness, Iatrogenic LSOA Dissection distal to LVA orig, Acute LICA cavernous occlusion at 24 h postprocedure, hemispheric infarct, death, Resolution of symptoms excellent; Return of left radial pulse, Good; partial improvement in visual field deficit, TIA postprocedure consisting of mild right-sided motor weakness, Excellent; no further TIAs, return of left radial pulse, Excellent; no further TIAs, return of right radial pulse, LSCA arteritis at 10 days and pseudoaneurysm requiring surgical stent removal and bypass grafting, Bilateral SCA stenosis, left subclavian steal, Episodic VBI, staggering gait, imbalance, presyncope with head turn, Vertebrobasilar territory ischemia, dizziness, vertigo, transient hemiplegia, Copyright © 1999 by American Heart Association. These attacks were different from the ones noted before the procedure because of their orthostatic independence. Posterior Cerebral Artery Stroke Treatment & Management Approach Considerations. 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. With the microcatheter in this position, 250 000 U urokinase was administered over a period of 15 minutes. RVAO indicates right vertebral artery origin; LVAO, left vertebral artery origin; PTA, percutaneous transluminal angioplasty; other abbreviations as in Table 1. Digital subtraction angiography of both common carotid arteries in the lateral projection reveals retrograde reconstitution of bilateral supraclinoid internal carotid artery flow though the ophthalmic artery (arrowheads) via external carotid artery collaterals (B; top panel, LCCA; bottom panel, RCCA). Analysis of our patient population identified hypertension as the most common medical problem, followed by smoking. Unauthorized Digital subtraction angiography (DSA) of the innominate artery in the anteroposterior projection performed 2 months before the procedure reveals stenosis of the right common carotid artery origin, chronic occlusion of the right subclavian artery (arrowhead at stump), and no evidence of right vertebral artery filling (B). Background: Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischemic stroke (ACIS) and posterior circulation ischemic stroke (PCIS). Given the lack of response to medical therapy and the extensive carotid occlusive disease, a decision was made to treat the vertebral artery stenosis. Clear guidelines and metrics exist for neuroendovascular treatment of large vessel anterior circulation strokes. Dr. Korya has nothing to disclose. Injection of the left subclavian artery showed excellent antegrade flow to the distal basilar, posterior cerebral, and superior cerebellar arteries, with retrograde flow into the right vertebral artery. Dr. Panezai has nothing to disclose. Figure 6. Dr. Mehta has nothing to disclose. Results from a number of studies evaluating the use of stents in the carotid artery have suggested that it may be useful in a subset of patients with very high medical risk or in patients with tandem lesions or bilateral carotid stenosis.1819 Although surgical repair of the vertebral artery origin and subclavian artery has been performed with excellent results by centers with large experience, it is technically more difficult and has less well defined outcomes in the patient cohort described in the present study, namely, patients with poor collateral flow with a high proportion of bilateral vertebral/subclavian and coexistent carotid disease.14202122 Surgical treatment has consisted of either ostial vertebral endarterectomy, subclavian endarterectomy, or reimplantation of the vertebral artery in the subclavian or carotid artery. Twenty percent of ischemic events in the brain involve the posterior circulation. Methods A total of 110 consecutive patients with posterior circulation stroke who underwent endovascular treatment in our institute in the period 1991-2015 were included. For example, a patient with complete homonymous hemianopsia has only two NIHSS points, but the patient might have a significant infarct in the occipital cortex, and their daily life will be affected drastically. Disclosure: Dr. Moussavi has nothing to disclose. Neurological outcome was determined at the longest duration of follow-up according to a 5-point scale as follows: excellent (score=1, asymptomatic, no neurological deficits and no symptoms of vertebrobasilar ischemia), good (score=2, no neurological deficits and at most 1 transient episode of vertebrobasilar ischemia over a period of 3 months after treatment), fair (score=3, minimal neurological deficit and at most 1 transient episode per month of vertebrobasilar ischemia), poor (score=4, no improvement compared with neurological status before treatment and/or persistent symptoms of vertebrobasilar ischemia), and death (score=5, regardless of cause). Table 3. A microguidewire was used to traverse the stenotic lesion and allow the passage of a stent-microcatheter, which is then positioned across the luminal irregularity (B). PCIS is a clinical syndrome associated with ischemia-related changes in the territory of the posterior circulation arteries. A percutaneous transfemoral approach was used to place a guide catheter at the origin of the left subclavian artery and traverse the lesion with a guidewire; a balloon-mounted Palmaz stent was deployed across the lesion to a diameter of 7 mm (arrowheads outline interstices) (B). May have additional signs of of Posterior Circulation Stroke- 5Ds: Dizziness , Dysarthria, Dystaxia, Diplopia, Dysphagia; Can be confused with acute vestibular syndrome (e.g. A prospective randomized trial comparing this option with the standard of care should be attempted to better elucidate the results. NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. labyrinthitis) Central vs. 1-800-AHA-USA-1 Determine when to triage posterior circulation stroke patients to ICU, neuro-stepdown or floor. Dr. Nizam has nothing to disclose. Angiography of the left (left panel, LCCA) and right (right panel, RCCA) common carotid arteries reveals bilateral occlusion of the internal carotid artery at its origin (arrowheads) (A). The results in this clinical retrospective series, the largest to date, point to endovascular balloon angioplasty and stent placement as a useful technique for the treatment of vertebrobasilar territory ischemia in patients who have failed best medical therapy. Enter and update disclosures at http://submit.neurology.org. Figure 6, C–G. The second complication consisted of a stent infection at 10 days after successful deployment (patient 21); the source of infection was presumed to be phlebitis from an ipsilateral distal infected intravenous site. higgs-boson@gmail.com. VBI indicates vertebrobasilar territory ischemia; PCA, posterior cerebral artery; VA, vertebral artery; LSCA, left subclavian artery; RVA, right vertebral artery; LVA, left vertebral artery; RSCA, right subclavian artery; PICA, posterior inferior cerebellar artery; ICA, internal carotid artery; HTN, hypertension; AAA, abdominal aortic aneurysm; DM, diabetes mellitus; Hchol, hypercholesterolemia; CAD, coronary artery disease; s/p, superior/posterior; MI, myocardial infarction; CA, cancer; PVD, peripheral vascular disease; GDC, Guglielmi detachable coil; BG, bypass graft; and CEA, carotid endarterectomy. Only 13.8% of lesions in that series were bilateral, compared with 76.2% in our patient population. The American Heart Association is qualified 501(c)(3) tax-exempt 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. 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. No comments have been published for this article. However, the benefit of endovascular treatment of ischemic stroke in the posterior circulation remains to … A 52-year-old right-handed man with diplopia, dysarthria, and left hemiparesis (patient 9). To be as concise as possible, I have eclectically selected key individuals and their contributions. Web page addresses and e-mail addresses turn into links automatically. Nevertheless, making the correct diagnosis is important, as these strokes have a high chance of recurrence, can be life threatening, and can lead to equally life-threatening complications. Severity of stenosis was computed according to the NASCET criteria with dimensions obtained either from the fluorographic appearance of a reference object or via the angiography digital computer system (Toshiba).11 Specifically, the diameter of maximal stenosis (DStenosis) was measured along with the most proximal diameter of the distal normal vessel (DNormal), and the degree of stenosis was computed as stenosis=[1−(DStenosis/DNormal)]×100.11 The paired Student’s t test and ANOVA were used in the comparison of numerical variables. More guidelines and information on Disputes & Debates, Neurology | Print ISSN:0028-3878 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. Of those 310 were posterior circulation strokes; of which, 34 underwent endovascular treatment. Exception: replies can include all original authors of the article. Despite emergent angiography and superselective infusion of urokinase, the occlusion could not be recanalized. Repeat angiography 7 months later revealed worsening in the stenosis and irregularity of the left vertebral artery origin. The ensuing arteritis required surgical removal of the stent and bypass grafting of the left vertebral artery; the patient had no neurological sequelae. Recent findings suggest that stroke aetiologies of PCS and ACS are more alike than dissimilar, suggesting … 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. 28 Little data about mechanical thrombectomy for the posterior circulation is available (in contrast with anterior circulation stroke), with the exception of proven basilar artery occlusion. 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). A 53-year-old right-handed man with hypertension and hyperlipidemia presented with transient attacks of visual loss and an occipital lobe infarct despite antiplatelet therapy 2 months before presentation (patient 18). Technical Summary of the Procedure Describing the Location of the Lesion, Pretreatment and Posttreatment Stenosis, Stent and Balloon Dimensions, Presence of Subclavian Steal Syndrome and Its Resolution by Treatment, Technical Complications if Any, and Treatment Steps Taken to Deal With the Complication. The patient was given intravenous anticoagulation with heparin, converted to warfarin, and discharged. Two vertebral arteries arise from the subclavian arteries and converge to form the basilar artery. Late-phase angiography shows flow reversal in the left vertebral artery consistent with a left subclavian steal, as suggested by negative velocities by cervical ultrasonography (short arrow shows direction of angiographic flow in early phase and long arrow in late phase) (A). Diagnosis can be challenging; clinical presentation and common pitfalls facing posterior circulation stroke have been discussed elsewhere. 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. A 68-year-old right-handed man with coronary artery disease, a history of 60-pack-year smoking, and laryngeal cancer status postradiation therapy noticed an increase in the frequency of episodes of orthostatic dizziness, visual changes, and subjective heaviness in the arms and legs lasting ≈30 seconds. 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). There were no clinically evident strokes in the posterior-circulation territory during the entire follow-up period. Copyright © 2016 by AAN Enterprises, Inc. Stay timely. A microguidewire and catheter were navigated into the very proximal left vertebral artery, where a small test injection confirmed intraluminal placement without intimal dissection. The majority of patients treated in our study (66.7%) were in Wityk group 4, that is, patients with significant blood flow restriction to the posterior circulation from vertebral artery or subclavian artery stenosis with a high frequency of contralateral stenosis or occlusion, and thus presented with hemodynamic spells or TIAs occurring with changes in orthostatic posture. Is she having a posterior stroke? 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. The patient tolerated the procedure with no neurological deficits and was discharged on postprocedure day 4 on oral warfarin therapy. Your last, or family, name, e.g. Identify patients with posterior circulation stroke. 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. The distribution of the posterior-circulation infarcts wasas follows: occipital lobe 58.3%, pontine 25%, and cerebellar 16.7%. It is associated with severe nausea and vomiting. 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. Clear guidelines and metrics exist for neuroendovascular treatment of large vessel anterior circulation strokes. 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. Postdeployment angiography of the left subclavian artery shows reestablishment of the native vessel caliber (C). The patient was placed on oral anticoagulant therapy but showed no improvement in symptoms after a period of 3 months. Exception: replies to comments concerning an article you originally authored do not require updated disclosures. An activated clotting time (ACT) was obtained before onset of the angiographic procedure. 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. For example, a patient with complete homonymous hemianopsia has only two NIHSS points, but the patient might have a significant infarct in the occipital cortex, and their daily life will be affected drastically. However, there are few trials evaluating the benefit of clot retrieval in posterior circulation strokes. A 7F to 9F access sheath was used (Avanti, Cordis Endovascular Systems). Distribution of patients at presentation based on the Wityk classification1 for extracranial proximal vertebral stenosis. In cases of milder stenosis (50% to 60%), such as in the case of intimal dissection, primary stenting was performed with either a self-expanding stent (WallStent, Schneider), a balloon-mounted stent (Palmaz, Johnson & Johnson), or a balloon-premounted stent (GFX, Arterial Vascular Engineering). 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). Altogether, patients with vertebral artery stenosis had an 8.5-fold higher stroke rate than a control population.13 Recently, Wityk et al1 analyzed the subset of patients in the New England Medical Center (NEMC) Posterior Circulation Registry with extracranial vertebral artery disease (V1 segment). use prohibited. The mean lesion stenosis before treatment was 75.2±14.1% and was decreased to a final value of 4.8±1.6% (P<0.001) after both angioplasty and stent deployment (Figure 3). Her past medical history is notable for type I diabetes. 1 2 Occlusive disease of the proximal and cervical portions of the vertebral artery represents a risk for posterior-circulation ischemia. After insertion of the stent and before deployment, an angiographic acquisition was performed to ascertain accurate location of the stent across the stenotic lesion. organization. Postangioplasty angiography revealed persistent stenosis of the origin, suggesting lesion recoil. Nine female and 12 male patients were treated; their ages ranged from 47 to 82 years, with a mean of 65.7 years. In the case of subclavian stenosis, surgical bypass procedures and carotid-subclavian bypass grafting have been surgically offered. The most common causes of posterior circulation large artery ischemia are atherosclerosis, embolism, and dissection. For categorical analysis, a Pearson’s χ2 test was used. Reference 1 must be the article on which you are commenting. A Palmaz stent was mounted on an angioplasty balloon catheter (Powerflex 7×20 mm, Cordis) and advanced across the lesion. The patient noted immediate improvement in her symptoms after the procedure and has remained asymptomatic at 8 months of follow-up. His motor examination revealed weakness in both upper (4/5) and lower (4/5, proximal greater than distal) extremities. Posttreatment angiography showed excellent restoration of antegrade flow in the left vertebral artery with complete patency of the vertebral artery origin to its normal native diameter. He has shown good recovery from his left hemiparesis and ophthalmoplegia and has had no further neurological episodes at 26 months of follow-up. Figure 3. Posterior circulation strokes affect the vertebrobasilar arterial system, account for about 20-25% of all ischemic strokes, and are a significant cause of patient disability and mortality. Nine patients (42.8%) had simultaneous unilateral or bilateral carotid stenosis of >60%, and 3 had unilateral or bilateral carotid occlusion (14.3%). Blood flow to the brain must be restored as quickly as possible. Statistical significance was assumed for a value of P<0.05. 7272 Greenville Ave. The New England Stroke Registry showed that 29% of patients with posterior circulation strokes died or suffered severe disability; however, individuals with embolic strokes fared worse than those with in situ atherosclerosis.8 However, reported mortality ranges from 45% to 86%.4 15 28 Predictors of poor outcome include older age, higher NIHSS score, lack of recanalization, atrial … 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. We report our endovascular treatment strategy for posterior circulation tandem occlusion. Fluorographic image of the Palmaz stent at the vertebral artery origin after deployment (H). Angiography of the left subclavian artery shows excellent filling of the left vertebral artery with reconstitution of the native vessel caliber (I). Figure 2. Mean discharge NIHSS was 9 (SD=11). Figure 1. 2016. A self-expanding stent (WallStent) was deployed in the left vertebral artery after percutaneous balloon dilatation (E, F).