Clinical Features and Prognosis in Young Adults with Infratentorial Infarcts

Malm, Jan; Kristensen, Bo; Carlberg, Bo; Fagerlund, Markku; Olsson, Tommy

doi:10.1159/000015979

Cited by 24 publications

(21 citation statements)

References 24 publications

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“…21 Furthermore, risk factor stratification might tend to miss younger stroke patients presenting with dizziness, who often lack traditional vascular risk factors, having vertebral artery dissection rather than atherosclerosis as the cause for posterior fossa infarction. 23,24 A well-studied expert approach relies on differentiating transient from persistent dizziness and then examining eye movements. 8,18,[25][26][27] Most stroke patients present with persistent symptoms.…”

mentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

309

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

309

351

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“…16 Outcome has been studied on a long-term basis in patients with stroke of the posterior circulation in general 18,22,23 subgroups of acute malignant or hemorrhagic infarctions of the cerebellum, 24 and has been identified in severely disabled patients. 23 Thus, little is known about acute deficits resulting from loss of cerebellar tissue only.…”

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confidence: 99%

Supratentorial Age-Related White Matter Changes Predict Outcome in Cerebellar Stroke

Grips

Sedlaczek

Bäzner

et al. 2005

Stroke

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Background and Purpose-Little is known about the relevance of age related white matter lesions (WMLs) concerning outcome after first-ever territorial stroke. Based on an index patient, we hypothesized that age and pre-existent WMLs rather than infarct volume and topography determine outcome. Patients and Methods-Thirty-four consecutive patients with magnetic resonance diffusion-weighted imaging-proven isolated acute cerebellar infarction were prospectively entered on our stroke data registry. Patients with pre-existent neurological deficits, hemorrhagic, or malignant cerebellar infarction were excluded. Patients were stratified using Rankin and Barthel disability scales into groups: I complete recovery, II moderate, and III significant disability 14 days after stroke onset. Results-Initial neurological and functional scores were similar among all the groups with vertigo, nausea, unsteadiness, and limb ataxia being the most common. Infarct volume, vascular territories, and comorbidity did not predict clinical outcome. In contrast, presence and severity of supratentorial WMLs and age significantly determined outcome by functional tests. Conclusions-In

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“…We finally selected 20 papers reporting 28 cases [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] . The clinical and radiological features of ischemic stroke patients with isolated PICA dissection from the literature are listed in table 4 .…”

Section: Literature Reviewmentioning

confidence: 99%

“…Follow-up evaluation was achieved during a median period of 3 months (IQR 3-12 months) in 24 of the 28 patients (86%). The median value of the mRS score was 0 (IQR 0-1) [4,6,[8][9][10][11][12][13][14][15][16][17][18][19][20][21] . One case developed subsequent SAH, which was fatal [14] .…”

Section: Literature Reviewmentioning

confidence: 99%

“…Etiological mechanisms of PICA territory infarctions mainly comprise atherosclerotic occlusive lesions of the vertebral artery (VA), cardioembolism and in situ branch artery disease of the PICA [2,3] . Ischemic stroke secondary to isolated dissection of the PICA is a very rare entity, with only several brief presentations published as case reports [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] .…”

Section: Introductionmentioning

confidence: 99%

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Isolated Posterior Inferior Cerebellar Artery Dissection as a Cause of Ischemic Stroke: Clinical Features and Prognosis

Kobayashi¹,

Ohara²,

Shiozawa³

et al. 2015

Cerebrovasc Dis

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Background: The purpose of this study was to clarify the incidence, clinical and radiological features and outcomes of isolated posterior inferior cerebellar artery (PICA) dissection in isolated PICA territory infarctions. Methods: We retrospectively reviewed consecutive inpatients with ischemic stroke secondary to isolated PICA dissection from our stroke database between January 2004 and December 2013 and reviewed the literature with regard to those patients. Results: Of 167 consecutive patients with an isolated PICA territory infarction, a total of 10 patients (6.0%, 3 women, 48.1 ± 7.1 years) were diagnosed as having an isolated PICA dissection. Patients with PICA dissection were younger (p < 0.001), more commonly experienced headache at onset (p = 0.008), less commonly had hyperlipidemia (p = 0.044) and showed a lower modified Rankin Scale score at discharge (p = 0.002) when compared with patients without arterial dissection. In 6 of these 10 patients, PICA dissections had not been suspected on initial magnetic resonance angiography (MRA) and were confirmed by follow-up MRA or digital subtraction angiography. In the follow-up period (median 1.5 years, interquartile range 0.5-6.3 years), there were no recurrent ischemic or hemorrhagic stroke events. Conclusions: Isolated PICA dissection as an etiological mechanism in isolated PICA territory infarctions may be more common than was previously recognized to be. The diagnosis of PICA dissection is often difficult and requires close and repeated morphological evaluation. We should carefully identify PICA dissections as a possible cause of PICA territory infarctions.

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Clinical Features and Prognosis in Young Adults with Infratentorial Infarcts

Cited by 24 publications

References 24 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Supratentorial Age-Related White Matter Changes Predict Outcome in Cerebellar Stroke

Isolated Posterior Inferior Cerebellar Artery Dissection as a Cause of Ischemic Stroke: Clinical Features and Prognosis

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