About 20-25% (range 17-40%) of the 150 000 ischaemic strokes in the United Kingdom each year affect posterior circulation brain structures (including the brainstem, cerebellum, midbrain, thalamuses, and areas of temporal and occipital cortex), which are supplied by the vertebrobasilar arterial system. 1 Early recognition of posterior circulation stroke or transient ischaemic attack (TIA) may prevent disability and save lives, but it remains more difficult to recognise and treat effectively than other stroke types. Delayed or incorrect diagnosis may have devastating consequences, including potentially preventable death or severe disability, if acute treatment or secondary prevention is delayed. 2 The annual adjusted incidence of posterior circulation infarction was estimated at 18 per 100 000 person years (95% confidence interval 10/100 000 to 26/100 000) in an Australian study. 3 Preceding posterior circulation TIA or other transient brainstem symptoms, particularly if recurrent, signal a high risk of impending ischaemic stroke and should prompt specialist urgent referral for further management. 4 New acute treatment options and stroke prevention strategies specific to the posterior circulation are important areas of active research. This review aims to demonstrate the importance and challenges of recognising and treating posterior circulation stroke, including the key differences between posterior and anterior circulation stroke. What is posterior circulation ischaemic stroke?Posterior circulation ischaemic stroke is a clinical syndrome associated with ischaemia related to stenosis, in situ thrombosis, or embolic occlusion of the posterior circulation arteries-the vertebral arteries in the neck, the intracranial vertebral, basilar, and posterior cerebral arteries, and their branches (fig 1⇓). Common sites of occlusion cause characteristic clinical patterns and syndromes (figs 1 and 2⇓).
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