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Posterior Circulation Stroke

Posterior Circulation Stroke. Christopher Lewandowski, M.D. Sunitha Santhakumar, M.D. Henry Ford Hospital Detroit, Michigan. Case Study. HPI:

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Posterior Circulation Stroke

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  1. Posterior Circulation Stroke Christopher Lewandowski, M.D. Sunitha Santhakumar, M.D. Henry Ford Hospital Detroit, Michigan

  2. Case Study • HPI: The patient is 41 y.o. male, with a past history of alcohol abuse, hypertension who presents to the ED with a chief complaint of right -sided weakness, slurred speech, and loss of balance. The symptoms began 90 minutes prior to arrival

  3. Case Study • PMHx: Alcohol Abuse, quit for 3 years Hypertension Seizures, Generalized, none for past 7 years • Medications Dyazide • Social Hx Smoking- 2 pack per day • ROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutes

  4. Case Study Physical Exam: BP- 149/79, P-100, RR-18, T-36.9 A& Ox3 on presentation, later became stuporous CN: dysarthria, pupils: R 3.5/ L 3.0 reactive L facial droop, gaze palsy to the L Motor: R arm and R leg weakness (3/5) Sensory: Decreased to light touch and pinprick on R Coordination: dysmetria on R (not out of proportion to weakness) NIH Stroke Scale score = 14

  5. What does this patient have? • Differential Diagnosis Stroke Intracerebral Hemorrhage Tumor VBI Migraine Seizure

  6. Posterior Circulation Stroke: Characteristics • Prodrome Occurs in about 60 % of patients with Basilar artery thrombosis • Common Prodromal Symptoms (in order of frequency) Vertigo and Nausea (30%) Headache, Neckache (20%) Hemiparesis (10%) Dysarthria, Diplopia (10%) Hemianopia (6%) Ferbert, Stroke 1990

  7. Was this Patient’s Dizziness Central or Peripheral Central Peripheral Intensity Mild Severe Tinnitis Rare Common CN findings Frequent None Nystagmus: Visual fixation No inhibition Inhibits Purely horiz. Common Rare Latency None 3-40 sec Fatigue None yes

  8. Posterior Circulation Stroke: Characteristics Clinical Findings: The 5 Ds: Dizziness, Diplopia, Dysarthria, Dysphagia, Dystaxia Hallmarks: Crossed findings Cranial nerve deficits - Ipsilateral Motor / Sensory deficits - Contralateral

  9. Posterior Circulation Stroke: Syndromes

  10. Posterior Circulation Stroke: Anatomy

  11. Posterior Circulation Stroke: Anatomy

  12. How do you evaluate this patient • Confirm the Diagnosis (Emergent) CT Scan MRI Blood Studies • Evaluation of Stroke Etiology (Inpatient) MRA / Angiography Echo / TEE TCD Carotid Doppler

  13. Case Study: CT Scan

  14. Case Study: MRI - DWI<12 Hours 4 Days

  15. Posterior Circulation Stroke: Prognosis • All Posterior Circulation Strokes New England Medical Center Posterior Circulation Stroke Registry: Mortality = 4% Minor or no Disability = 79% • Locked In Syndrome Mortality > 90%

  16. Posterior Circulation Stroke: Treatment • Conservative Treatment Antiplatelet and Antithrombotic • Thrombolytic Treatment Intravenous: if the patient presents within 3 hours symptom onset and meets all treatment criteria Intra-Arterial Therapy: local infusion of thrombolytic agent into vessel or clot

  17. Posterior Circulation Stroke: Treatment • Conservative Treatment Antiplatelet and Anti thrombotic Therapy Uncontrolled, Retrospective Studies , 1950s & 1960s Compared to historical controls, patients treated with heparin had lower mortality (8-15% vs. 40-60%) Stopped progression of VBI to infarction • TOAST Trial No evidence to support heparinization in acute stroke

  18. Posterior Circulation Stroke: Treatment • Intravenous Thrombolysis NINDS rt-PA Acute Stroke Trial t-PA approved within 3 hours of symptom onset few posterior circulation strokes • How do you know if a patient will progress to locked-in syndrome

  19. Posterior Circulation Stroke: Treatment • Intra-arterial Thrombolysis, Local No randomized controlled trials completed Multiple small series and reports • Results (Over 200 patients treated) Mortality 20-60% , assoc. with lack of recanalization Favorable outcomes in 25%-60% ICH rate low, 0-15%

  20. Posterior Circulation Stroke Future Treatment • Intra-arterial Thrombolysis Superselective approach, micro-catheters • Angioplasty • Angio-jet

  21. Case Study: Outcome • The patient received intravenous thrombolysis after his mental status deteriorated with a NIH-SS score of 22 • He improved initially, but without complete resolution of symptoms • On day 4, the NIH - SS score was 10 • MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized, • Cardiac evaluation was negative • He was discharged on Coumadin to Rehab

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