Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management

Nouh, Amre; Remke, Jessica; Ruland, Sean

doi:10.3389/fneur.2014.00030

Cited by 208 publications

(215 citation statements)

References 107 publications

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“…Common mimics include VA dissection; vasculitis; reversible cerebral vasoconstriction syndrome; mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes; and subclavian steal phenomenon or cardiac or paradoxical embolism. 22 BHS is a rare disorder and its management has not been standardized, but it is most often surgical. 5 An initial conservative approach may include neck immobilization using a cervical collar or neck brace.…”

Section: Discussionmentioning

confidence: 99%

Pearls & Oy-sters: Bow hunter syndrome: A rare cause of posterior circulation stroke

Jadeja

Nalleballe

2018

Neurology

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PearlsBow hunter syndrome (BHS) is an uncommon cause of vertebrobasilar insufficiency that results from occlusion or injury to the vertebral artery (VA) during neck rotation.The cause is often a bony abnormality that may compress the VA compromising distal flow or lead to vessel wall injury resulting in thromboembolism. Oy-stersPosterior circulation strokes in young individuals should alert the neurologist to suspect BHS, especially if high cervical spine abnormalities are detected on initial head imaging.Dynamic occlusion of the VA may not be evident on angiography if a thromboembolic mechanism such as a pseudoaneurysm is involved.A 24-year-old man with no relevant medical history presented to our institution with a week of intermittent dizziness exacerbated by turning his head to the left. He acutely developed diplopia and disorientation on the day of presentation to the emergency room. He reported similar complaints a month prior. There was no history of fevers, rashes, headache, or neck trauma. There was no family history of similar complaints, vascular or connective tissue diseases, strokelike episodes, seizures, or early-onset dementia. Examination demonstrated mild impairment of cognition and a right hemiparesis. Initial head CT revealed congenital atlas nonunion (C1) with fusion of the second and third vertebral bodies (C2-C3). Brain MRI revealed diffusion restriction in the left thalamus and bilateral dorsal midbrain indicative of multiple acute infarctions. Chronic infarctions were also present in the right cerebellum, which indicated prior episodes of ischemia. A series of dynamic X-rays showed malalignment of the lateral masses of the atlas with C2, but there was no evidence of instability. CT angiography (CTA) revealed the presence of a pseudoaneurysm of the right VA at its exit from the C2 transverse foramen. This was suspected to be the source of the posterior circulation emboli. Left VA was unremarkable. There was no evidence of VA dissection on CTA (figure). Magnetic resonance angiography (MRA) with fat-suppressed images of the neck was not performed. The rest of the workup including complete blood count, serum chemistry and lipids profile, glycosylated hemoglobin levels, liver function tests, hypercoagulability studies, D-dimer levels, transthoracic echocardiography, and short-term Holter monitoring were unremarkable. A transesophageal echocardiogram was not performed because of concerns for further neck manipulation.A clinical diagnosis of BHS was made. Aspirin was initiated for secondary stroke prevention and the patient was referred for an evaluation for corrective cervical spinal surgery. Approximately 1 week later, the patient returned to an outside hospital with new cerebellar infarcts. Digital subtraction angiography (DSA) confirmed a right VA pseudoaneurysm that was suspected to have been caused by repetitive mechanical injury to the right VA from his congenital cervical spinal abnormalities during neck rotation. Dynamic occlusion of the VAs could not be reproduced

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Section: Discussionmentioning

confidence: 99%

Pearls & Oy-sters: Bow hunter syndrome: A rare cause of posterior circulation stroke

Jadeja

Nalleballe

2018

Neurology

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“…22 Vertebral arterial dissection may present with occipital headaches and symptoms suggestive of brainstem or posterior circulation infarction. 23 Vascular imaging is paramount in diagnosis, and although digital subtraction angiography is considered the gold standard, vascular imaging with CTA or MRA are both acceptable techniques in the emergency department setting. 24 Antiplatelet therapy has been shown to be as effective as anticoagulation in treatment, and endovascular stabilization may be warranted in some cases.…”

Section: Reversible Cerebral Vasoconstrictive Syndrome (Rcvs) Is a CLmentioning

confidence: 99%

Headache in the Emergency Room

Kahkeshani¹,

Sheikh²

2017

US Endocrinology

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Headache is seen in the emergency room (ER) on a daily basis and is a vague symptom, which can be a part of many different types of conditions and diseases. Although most people who come to the ER will have a benign headache, it is important to make sure that dangerous causes of headache are ruled out. There are a number of features that may alert someone to a secondary cause of headache. This article highlights two specific secondary headache syndromes, including carotid dissection and reversible cerebral vasoconstriction syndrome. It also broadly points out other possible causes of secondary headache. The last section focuses on a common primary headache that presents to the ER, migraine and its treatment.

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“…Prior research showed that only 3.2% of patients presenting with dizziness, vertigo or imbalance were diagnosed with a stroke or Transient Ischaemic Attack (TIA) [2]. Vestibular symptoms such as vertigo can be attributed to both peripheral causes such as vestibular neuritis or central causes like brainstem/cerebellar stroke.…”

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confidence: 99%

MRI Yield of Posterior Fossa Strokes in ‘Dizzy’ Patients

Lam¹

2016

NMRR

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pre-syncope and unsteadiness [1]. The posterior circulation is defined primarily by the vertebro-basilar arterial system, which arises from the subclavian arteries. Infarcts affecting the superior or Posterior Inferior Cerebellar Arteries (PICA) can cause symptoms of vertigo.Many patients with unexplained dizziness ultimately undergo an MRI scan to rule out a posterior circulation ischaemic stroke. Prior research showed that only 3.2% of patients presenting with dizziness, vertigo or imbalance were diagnosed with a stroke or Transient Ischaemic Attack (TIA) [2]. Vestibular symptoms such as vertigo can be attributed to both peripheral causes such as vestibular neuritis or central causes like brainstem/cerebellar stroke. In a study of 240 patients who presented with vertigo lasting more than a day and no other focal neurological deficits, 10% were diagnosed with cerebellar strokes but ischaemia associated with vertigo is often accompanied by other brainstem signs [3]. However, only 17% of patients with confirmed PICA strokes had symptoms of vestibular neuritis [3]. Manoeuvres such as Dix-Hallpike can help distinguish between peripheral or central aetiology since none of the patients who had symptoms of vestibular neuritis due to ischaemic stroke had a positive head thrust [4]. Nevertheless, it has been argued that MRI plays an important role in differentiating between peripheral and central aetiology when clinical diagnosis fails [5].CT scan has been proven to have poor sensitivity in diagnosing posterior Fossa strokes in patients with dizziness and vertigo as it provides suboptimal visualisation of structures secondary to artefact produced by bony structures of the cranial base and therefore early ischaemic events are missed [5,6]. Accordingly, diffusion weighted MRI scans is more commonly used, but even this modality misses up to 20% posterior Fossa infarcts in the first 24-48 hours of presentation [1]. The yield of MRI for stroke in this cohort of patients was only 21%, with a diagnostic impact on management for 22% of these patients [5]. This unreliability of MRI scan is reinforced by a study which showed that diffusion weighted imaging was falsely negative in 12 of patients with acute vestibular symptoms and posterior Fossa strokes [7]. MethodA total of 603 MRI scans were performed for patients presenting with vertigo and dizziness with suspicion of cerebellar or brainstem infarcts during the one year period analysed at Royal Derby Hospital. Prior research showed that there is a low yield of posterior circulation infarcts diagnosed on MRI in this cohort of patients with dizziness [1,5].Data was accumulated for those 603 patients with MRI scans through screening of patients who underwent MRI scan in the last year and key words on the request or report cards included 'cerebellar infarct' , 'cerebellar stroke' , 'brainstem stroke' , 'vertigo' , 'dizziness' , 'ataxia' or 'unsteadiness' . Methods: 588 patients under went MRI within a one-year period. Data was ascertained through requests and results on ICM compute...

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Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management

Cited by 208 publications

References 107 publications

Pearls & Oy-sters: Bow hunter syndrome: A rare cause of posterior circulation stroke

Pearls & Oy-sters: Bow hunter syndrome: A rare cause of posterior circulation stroke

Headache in the Emergency Room

MRI Yield of Posterior Fossa Strokes in ‘Dizzy’ Patients

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