Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke

Goldmakher, Gregory V.; Camargo, Erica C.; Furie, Karen L.; Singhal, Aneesh B.; Roccatagliata, Luca; Halpern, Elkan F.; Chou, Maggie; Biagini, Trese; Smith, Wade S.; Harris, Gordon J.; Dillon, William P.; González, Ramón; Koroshetz, Walter J.; Lev, Michael H.

doi:10.1161/strokeaha.108.516690

Cited by 95 publications

(69 citation statements)

References 19 publications

(18 reference statements)

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“…163 The hyperdense basilar artery sign has been described with similar implications as the hyperdense MCA sign. 164, 165 The presence, clarity, and extent of early ischemia and infarction on NECT are correlated with a higher risk of hemorrhagic transformation after treatment with fibrinolytic agents. In combined data from 2 trials of intravenous rtPA administered within 3 hours of symptom onset, NECT evidence of early clear hypodensity or mass effect was accompanied by an 8-fold increase in the risk of symptomatic hemorrhage.…”

Section: Recommendationsmentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

Stroke

5,336

1,801

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Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

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Section: Recommendationsmentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

Stroke

5,336

1,801

View full text Add to dashboard Cite

show abstract

“…In the correct clinical context, the hyperdense basilar artery sign is associated with basilar thrombus, but it is not always present and can be easily overlooked. 10 Ultimately in patients with clinical neurological findings suggestive of a posterior circulation event, further assessment with angiography via CT angiogram, magnetic resonance angiography, or conventional angiography is required to visualize the basilar artery and rule out filling defects consistent with BAO.…”

Section: Discussionmentioning

confidence: 99%

Significant Period Between Presentation and Diagnosis in Basilar Artery Occlusion

Organek

Milano

Donohue

et al. 2015

Stroke

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A 37-year-old woman without significant medical history was seen at an outside facility with 7 days of headache and fluctuating right hemiparesis. She had a normal head computed tomography (CT). She was diagnosed with migraine, received analgesics, and was discharged. Her headache and hemiparesis had improved but did not completely resolve. Three days later, she presented to a second facility with the same symptoms of headache and right-sided weakness and more recent onset of nausea and vomiting. She was again treated for migraine but developed worsening hemiparesis and difficulty with secretions requiring intubation. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed basilar artery occlusion (BAO) and left vertebral artery dissection. She underwent successful endovascular recanalization of the basilar artery but severe neurological deficits remained. Case TwoA 41-year-old was brought to the emergency department where she was poorly responsive but had a nonfocal neurological examination. Urine toxicology showed cocaine and marijuana. Head CT was limited by motion but was otherwise unremarkable. She was initially treated for presumed seizures, but her level of consciousness worsened and she was intubated. She was empirically treated for meningitis/encephalitis. Thirty-six hours after admission when the cerebrospinal fluid was found to be normal and she failed to improve, magnetic resonance imaging and magnetic resonance angiography was performed, which demonstrated BAO with a large pontine infarct. Work-up showed lupus anticoagulant. Case ThreeA 45-year-old woman with lupus presented with 24 hours of nausea/vomiting, intermittent dizziness, dysarthria, and rightsided hemiparesis. Head CT was unremarkable. On admission, neurological examination showed right facial droop, dysarthria, right-sided hemiparesis, hyperreflexia, and a right extensor plantar reflex. Non-vascular etiologies were pursued initially. One day after presentation, worsening of right-sided weakness and headache prompted vascular imaging showing proximal BAO. Endovascular recanalization was attempted but was unsuccessful. Case FourA 57-year-old man with a history of stent-assisted coiling of a basilar artery aneurysm presented with brief loss of consciousness, transient dysarthria, decreased sensation in his left face, and left upper extremity drift. Head CT showed stent artifact. Intravenous tPA was not given because of his low National Institute of Health stroke scale of 2. He then developed seizure-like activity, deteriorated further neurologically, and required intubation. He was treated for seizures/nonconvulsive status epilepticus and transferred to a tertiary facility. On arrival, he was unresponsive, had absent brain stem reflexes, and extremity movement limited to triple flexion. Repeat head CT demonstrated extensive brain stem hypodensity. Diagnostic angiography demonstrated BAO, but no intervention was attempted because of extensive infarction. It was later learned that he had not taken antiplatelet agent...

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“…27 However, in patients where there is a high pretest probability of posterior circulation stroke, the presence of a hyperdense BA is a specific predictor of BAO. 28 When a hypodensity is seen in the posterior circulation territory on the CT scan, the posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS), developed and validated by Volker Puetz, can be used to quantify early ischemia. This scoring system allots the posterior circulation 10 points in total with points subtracted for ischemic changes.…”

Section: Special Topics In Imaging Of Bao and Posterior Fossamentioning

confidence: 99%

Basilar Occlusion Syndromes

Demel

Broderick

2015

The Neurohospitalist

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Basilar artery occlusions (BAOs) are a subset of posterior circulation strokes. Particular issues relevant to BAOs include variable and stuttering symptoms at onset resulting in delays in diagnosis, high morbidity and mortality, and uncertain best management. Despite better imaging techniques, diagnosis, and therefore treatment, is often delayed. We will present the most common signs and symptoms of posterior circulation strokes. Data on optimal treatment strategies are gathered from multiple case series, registries, and one randomized trial, which was stopped early. Possible etiologies of BAOs, acute, and subacute treatment strategies and special topics in neuroimaging of the posterior fossa are discussed. This review may be helpful to neurohospitalists who are managing patients with acute stroke as well as emergency room physicians and neurologists.

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Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke

Cited by 95 publications

References 19 publications

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Significant Period Between Presentation and Diagnosis in Basilar Artery Occlusion

Basilar Occlusion Syndromes

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