Ischemic Posterior

Circulation Stroke

Christopher Lewandowski, M.D.

Residency Program Director
Department of Emergency Medicine
Henry Ford Hospital, Detroit, MI

Sunitha Santhakumar, M.D.

Department of Emergency Medicine
Henry Ford Hospital, Detroit, MI
 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.

Christopher Lewandowski, MD
 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
Christopher Lewandowski, MD
 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
Christopher Lewandowski, MD
 What does this patient have?
Differential Diagnosis
Stroke
Intracerebral Hemorrhage
Tumor
VBI
Migraine
Seizure

Christopher Lewandowski, MD
 Epidemiology
Stroke - leading cause of adult disability in the USA
20% of strokes involve the vertebrobasilar arteries
20% of global cerebral blood flow is vertebrobasilar
Vertebrobasilar ischemia ranges from intermittent
vascular insufficiency (VBI) to total basilar artery
occlusion (BAO)
20% - 60% with unfavorable outcome
Overall mortality 4%, BAO - 90% mortality

Christopher Lewandowski, MD
 Risk Factors: Uncontrollable
Age
Stroke risk doubles for every decade over 55
Gender, Males - 1.3 x
Males have a higher risk, but females live longer,
therefore there are more female stroke survivors
Heredity
African Americans - 2x
Family History
Previous stroke or TIA - 10x
Diabetes - 3x (even if well controlled)
Christopher Lewandowski, MD
 Risk Factors: Controllable
Hypertension - 6x (consistently >140/90)
Atrial Fibrillation - 6x
Smoking - 2x
Hypercholesterolemia > 200
Heart Disease - 2x
Alcohol, (> 4oz/day)
Obesity
BMI > 30
35 inch waist in women, 40 inches in men

Christopher Lewandowski, MD
 Risk Factors
Vertebrobasilar Ischemia

Risk factors for the Posterior circulation

are the same as for the anterior circulation

Hypertension, diabetes mellitus,

hyperlipidemia, and tobacco are
especially important for the posterior
circulation
Christopher Lewandowski, MD
Posterior Circulation Stroke: Anatomy

Christopher Lewandowski, MD
Posterior Circulation Stroke: Anatomy

Christopher Lewandowski, MD
 Pathology
Atherosclerosis Subclavian steal syndrome
In situ thrombosis Symptoms brought on by
Often complete arm exercise
occlusion Trauma
90% mortality
Especially in the young
Embolization (20%-50%)
Vertebral artery
Heart or proximal
vessels dissection
May cause VBI Lacunar (small vessel
Good prognosis disease)

Christopher Lewandowski, MD
 Emergency Department Presentation

Prodrome very common

60 % of patients with Basilar artery
thrombosis
Stuttering or progressive onset of
symptoms
2 weeks prior to ED presentation

Christopher Lewandowski, MD
 Emergency Department Presentation
Prodromal Symptoms (in order of frequency)
Vertigo and Nausea (30%)
Headache, Neckache (20%)
Hemiparesis (10%)
Dysarthria, Diplopia (10%)
Hemianopia ( 6%)

Ferbert, Stroke 1990

Christopher Lewandowski, MD
 Emergency Department Presentation

Clinical Findings: Depends on the syndrome

Range: asymptomatic to comatose
The 5 Ds: Dizziness, Diplopia, Dysarthria,
Dysphagia, Dystaxia
Hallmarks: Crossed findings
Cranial nerve deficits - Ipsilateral
Motor / Sensory deficits - Contralateral

Christopher Lewandowski, MD
 Vertigo
Hallucination of movement of the patient or the
environment, not associated with loss of
consciousness
Visual, proprioceptive, and vestibular systems
maintain position (Romberg test)
Semicircular canals connect to the vestibular
nuclei in the brainstem via CN VIII
Vestibular nuclei connect to the cerebellum,
MLF (eye movement) and the vestibulospinal
tract
Christopher Lewandowski, MD
 Nystagmus
Nystagmus means nodding off (as in
sleeping during this lecture, slow sleep
phase with rapid correction)
Nystagmus is named for its fast
component
Medial longitudinal fasciculus coordinates
the ipsilateral medial rectus (CN III) and
the contralateral lateral rectus (CN VI)
Inner ear provides symmetric resting
discharge Christopher Lewandowski, MD
 Nystagmus
Loss of input from one side leaves the
other side unopposed
Unopposed stimulation causes a slow
drift toward the diseased side
Cerebral cortex corrects for slow drift
with a very rapid return toward a more
normal position
The brainstem can compensate for
asymmetric peripheral inputs leading to
latency, fatigue, and habituation
Christopher Lewandowski, MD
 Vertebrobasilar
Ischemia: Syndromes
VBI
Common term for TIAs of the vertebrobasilar
system
Patients often asymptomatic in ED
Frequent episodes, especially as prodromal sx
Requires evaluation of etiology
Very rare to present as vertigo alone
Difficult to distinguish from other causes of
dizziness

Christopher Lewandowski, MD
 Was this Patients Dizziness
Central or Peripheral
Central Peripheral
Intensity Mild Severe
Tinnitis Rare Common
CN findings Frequent None
Nystagmus:
Visual fixation No inhibition Inhibits
Horizontorotary Rare Common
Latency None 3-40 sec
Fatigue None Christopher Lewandowski,
yesMD
Posterior Circulation Stroke: Syndromes
VBI, brainstem TIAs:
Occur over days-weeks
Intermittent fluctuating brainstem sx
Dizziness plus cranial nerve symptoms
Rarely dizziness alone

Christopher Lewandowski, MD
 Vertebrobasilar
Ischemia: Syndromes
Branch artery occlusions
Produce a specific stroke syndrome for each artery
Longer and circumfrential arteries
Small penetrating branches supplying midline
structures and causing lacunar syndromes
Characterized by the 5Ds and crossed findings
The severity of the stroke depends on the collateral
blood flow and the location of the occlusion

Christopher Lewandowski, MD
Posterior Circulation Stroke: Syndromes
LOCATION NAME IPSILATERAL CONTRALATERAL

Cerebrum Top of the Bilateral loss of vision with denial of

Basilsr, Antons blindness , Somnolence, Confusion

Midbrain Weber 3rd nerve palsy Hemiplegia

Pons Millard-Gubler Facial Palsy Hemiparesis

Medulla Wallenburg Nystagmus, Pain and

Vertigo, Horners, Temperature loss
Facial sensory
loss

Christopher Lewandowski, MD
 Vertebrobasilar
Ischemia: Syndromes
Basilar artery occlusion
75% with prodromal symptoms
63% with gradual and progressive onset
Can produce a locked-in syndrome
Awake, quadriplegia, bilateral facial and
oropharyngeal palsy, preserved vertical
gaze
May present comatose if reticular activating
system is involved

Christopher Lewandowski, MD
 Emergency Department Diagnosis
History
Prodrome
Dizziness
Physical Exam,
Blood pressure in both arms
Diagnostic Studies
Blood tests,CXR, EKG
Imaging
Christopher Lewandowski, MD
 Emergency Department Diagnosis
Confirm the Evaluation of Stroke
Diagnosis Etiology (Inpatient)
(Emergent) MRA / Angiography
CT Scan Echo / TEE
MRI, MRA, DWI TCD
TCD Carotid Doppler
Angiography (DSA)

Christopher Lewandowski, MD
Emergency Department Evaluation
CT scan - head, noncontrast
Necessary to rule out intracerebral hemorrhage
Most sensitive test for ICH
Poor for posterior fossa visualization
Bone artifact
Can pick up Basilar artery thrombosis
Highly specific sign, very low sensitivity
CT Angiography (spiral CT)
Reliably assesses basilar artery patency, inconclusive in
patients with advanced arterial calcification
Christopher Lewandowski, MD
Case Study: CT Scan

Christopher Lewandowski, MD
Baseline CT scan

Christopher Lewandowski, MD
Emergency Department Evaluation
MRI - long scan times, unavailable, access to
patient is poor
Standard MRI, not reliable for ICH in first hours
Major advantage is Posterior Fossa imaging
MR Angiography -reliable evaluation of arteries
for VBI, BAO
DWI - Diffusion weighted imaging demonstrates
infarcted tissue, this is not a contraindication to
thrombolysis
Christopher Lewandowski, MD
MRI-DWI in the posterior fossa

Christopher Lewandowski, MD
Emergency Department Evaluation
TCD
Assesses flow through Vertebrobasilar
system
Limited in BAO
Patient anatomy, penetration to distal BA
difficult
Brandt: TCD diagnostic in 7 of 19 patients
with suspected BAO, 2 of 19 false negatives
Low sensitivity for BAO, not useful in ED
Christopher Lewandowski, MD
Emergency Department Evaluation
Digital subtraction angiography
Gold Standard for diagnosis of BAO
Time consuming, expensive, invasive
Requires patient cooperation,
anesthesia
Allows for intra-arterial intervention
Thrombolysis, angioplasty

Christopher Lewandowski, MD
Emergency Department Management
Stabilization
Ensure oxygenation and ventilation
Optimize cerebral blood flow by managing
the blood pressure and hydration carefully,
as autoregulation lost, ischemic areas
become perfusion dependant
Avoid glucose, avoid hypotension, treat
fevers aggressively
Evaluate for anticoagulation or thrombolysis

Christopher Lewandowski, MD
Emergency Department Management

Conservative Treatment
Antiplatelet and Antithrombotic
Thrombolytic Treatment
Intravenous: within 3 hours symptom onset
and the patient meets all treatment criteria
Intra-Arterial Therapy: infusion of
thrombolytic agent into vessel or clot within
24 hours of onset of symptoms
Christopher Lewandowski, MD
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

Christopher Lewandowski, MD
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

Christopher Lewandowski, MD
Posterior Circulation Stroke: Treatment
Intra-arterial Thrombolysis
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%

Christopher Lewandowski, MD
 Posterior Circulation Stroke
Future Treatment

Intra-arterial Thrombolysis
Superselective approach, micro-catheters
Angioplasty
Angio-jet

Christopher Lewandowski, MD
What is the prognosis for this patient ?
All Posterior Circulation Strokes
New England Medical Center Posterior Circulation
Stroke Registry:
Mortality = 4%
Minor or no Disability = 79%
Locked In Syndrome (Basilar artery occlusion)
Mortality > 90%
How do you know if a patient will progress to
locked-in syndrome ? Observation

Christopher Lewandowski, MD
 Case Study: Outcome
The patient mental status deteriorated, repeat NIH-SS
score was 22
He received intravenous thrombolysis
He had significant early improvement 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

Christopher Lewandowski, MD
 Case Study: MRI - DWI
<12 Hours 4 Days

Christopher Lewandowski, MD
 Summary
Posterior Circulation Strokes are
characterized by the 5Ds and crossed
findings
Maintain a high index of suspicion for
prodromal symptoms - vertigo with CN sx
The locked-in syndrome consists of
quadriplegia, bilateral facial and
oropharyngeal palsy; but preservation of
cortical function and vertical gaze
Christopher Lewandowski, MD
 Summary
The prognosis for vertebrobasilar
ischemia is generally good, except for
locked-in syndrome (basilar artery
occlusion)

Treatment consists of conservative

therapy (aspirin and heparin) or IV
thrombolysis (<3 hrs) or IA thrombolysis
(up to 24 hours)
Christopher Lewandowski, MD
 Question 1
All of the following are posterior circulation syndromes
except:
A) Ipsilateral CN III palsy with contralateral
hemiplegia
B) Ipsolateral facial palsy with contralateral
hemiplegia
C) Hemiaplegia and hemisensory loss of the face arm and
leg on one side of the body
D) Ipsilateral ataxia and Horners with contralateral
loss of pain and temperature sensation
Christopher Lewandowski, MD
 Question 2
Locked-in Syndrome consists of:
A) Coma with quadriplegia
B) Bilateral upper extremity weakness greater
than lower extremity weakness
C) Quadriplegia, bilateral facial and
oropharyngeal palsy but preservation of
cortical function and vertical gaze
D) cranial nerve findings contralateral to motor
and sensory findings
Christopher Lewandowski, MD
 Question 3
Vertigo of central origin is:
A)Generally severe and sudden in onset
B)Is a very common isolated prodromal
symptom of VBI
C)Is often associated with tinnitus
D)Fatigues easily
E)Is generally associated with cranial
nerve findings
Christopher Lewandowski, MD
 Question 4
Proven therapy for posterior circulation
stroke includes:
A)Heparin
B) Low molecular weight heparin
C) IV thrombolysis
D) Intra-arterial regional thrombolysis
E) Intra-arterial local thrombolysis
Christopher Lewandowski, MD
 Question 5
Overall mortality for posterior
circulation strokes is:
A)< 5%
B) 20%
C) 40%
D) 70%
E) > 90%
Christopher Lewandowski, MD
 Question 6

Mortality for Locked-in Syndrome is:

A)< 5%
B) 20%
C) 40%
D) 70%
E) > 90%

Christopher Lewandowski, MD