Patterns of ischemic posterior circulation strokes: A clinical, anatomical, and radiological review

Background Posterior circulation and anterior circulation strokes share many clinical, pathogenetic and radiological features, although some clinical signs are highly specific to posterior circulation strokes. Arterial stenosis and occlusions occur in significant numbers in both acute posterior circulation and anterior circulation strokes, making them good candidates for endovascular treatment. Among posterior circulation strokes, basilar artery occlusions stand out because of the diagnostic and acute treatment challenges. Methods We reviewed the literature on clinical stroke syndromes and neuroimaging findings and systematically describe for each anatomical site of stroke the detailed clinical and radiological information (anatomical representation, diffusion weighted imaging and angiographic sequences). The principles of neuroimaging of posterior circulation strokes and the prognosis for each stroke localization are also discussed. Review summary Stroke syndromes in the territories of the vertebral, basilar, cerebellar, and posterior cerebral arteries are presented. Features typical of posterior circulation strokes are highlighted, including patterns of basilar artery occlusions. Clinical severity and prognosis of posterior circulation strokes are highly variable, and given that they are more difficult to detect on CT-based neuroimaging, magnetic resonance imaging is the technique of choice in suspected posterior circulation strokes. Rapid identification of arterial occlusion patterns may provide prognostic information and support acute revascularization decisions. Conclusions Posterior circulation stroke syndromes tightly reflect lesion localization and arterial occlusion patterns. Although many clinical and pathogenetic features are similar to anterior circulation strokes, notable differences exist in terms of clinical presentation, stroke mechanism, prognosis, and response to acute recanalization.

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149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

British Journal of Surgery ◽

10.1093/bjs/znab134.234 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

K Daga ◽

M T Ahmad ◽

M Taneja

Keyword(s):

Treatment Option ◽

Current Literature ◽

Basilar Artery ◽

Cerebral Angiography ◽

Posterior Circulation ◽

Anterior Circulation ◽

Acute Setting ◽

Post Procedure ◽

Basilar Artery Stenosis

Abstract The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

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Permanent Deployment of the Solitaire FR™ Device in the Basilar Artery in an Acute Stroke Scenario

Interventional Neurology ◽

10.1159/000480245 ◽

2017 ◽

Vol 7 (1-2) ◽

pp. 6-11

Author(s):

Miguel S. Litao ◽

Erez Nossek ◽

Keith DeSousa ◽

Albert Favate ◽

Eytan Raz ◽

...

Keyword(s):

Acute Stroke ◽

Basilar Artery ◽

Effective Means ◽

Posterior Circulation ◽

National Institutes Of Health ◽

Anterior Circulation ◽

Nihss Score ◽

Vessel Patency ◽

Solitaire Fr

Background: Scarce reports exist of permanent deployment of Solitaire FR™ devices for arterial steno-occlusive disease as it is primarily indicated for temporary deployment for thrombectomy in large-vessel, anterior-circulation ischemic strokes. Even more scarce are reports describing permanent deployment of the Solitaire device for posterior circulation strokes. Summary: We present 2 cases where the Solitaire device was electrolytically detached to re-establish flow in an occluded or stenotic basilar artery in acutely symptomatic patients. In both cases, a 4 × 15 mm Solitaire device was positioned across the stenotic or occluded portion of the basilar artery and electrolytically detached to maintain vessel patency. Both cases had good clinical outcomes with a National Institutes of Health Stroke Scale (NIHSS) score of 1 (from 24) on 90-day follow-up and an NIHSS score of 2 (from 7) on 30-day follow-up. Key Messages: Permanent deployment of the Solitaire device may potentially be a safe and effective means of maintaining vessel patency in an occluded or stenotic basilar artery.

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Association Between Configuration of Basilar Artery and Vessel Wall Features: A Prospective High-resolution MR imagine Study

10.21203/rs.2.11252/v1 ◽

2019 ◽

Author(s):

Ziqi Xu ◽

Mingyao Li ◽

Zhikai Hou ◽

Jinhao Lyu ◽

Na Zhang ◽

...

Keyword(s):

High Resolution ◽

Basilar Artery ◽

Vessel Wall ◽

Cerebral Arteries ◽

Arterial Stenosis ◽

Intraplaque Hemorrhage ◽

Resonance Imaging ◽

Intracranial Arterial Stenosis ◽

Future Studies ◽

The Relationship

Abstract Background We aimed to investigate the relationship between distal and proximal anatomical configurations of basilar artery (BA) and vessel wall features on high resolution magnetic resonance imaging (HRMRI). Methods From September 2014 to January 2017, patients with suspected symptomatic intracranial arterial stenosis underwent HRMRI. Patients with severe BA stenosis were enrolled. Configurations of BA were divided complete and incomplete groups based on with or without bilateral vertebral arties and posterior cerebral arteries. Culprit vessel wall features on HRMRI included enhancement grade, intraplaque hemorrhage, remodeling patterns, and plaque distribution. Culprit vessel wall features were compared between complete and incomplete groups. Results Among the 298 consecutively enrolled patients, 34 consecutive patients had severe BA stenosis. Seventeen patients had complete configuration and 14 patients with incomplete configuration. There were no statistics difference in vessel wall features between complete and incomplete groups configuration groups. The proximal configuration of BA was associated with intraplaque hemorrhage(p=0.002) and the distal configuration of BA correlated with strong enhancement of BA plaque(p=0.041). Conclusions The complete and incomplete groups configuration of BA did not associate with vessel wall features. The proximal configuration of BA was related with intraplaque hemorrhage and the distal configuration of BA was associated with strong plaque enhancement. These findings are continuously needed to confirmed in future studies.

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Revascularization surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion

Journal of Neurosurgery ◽

10.3171/2018.9.jns181075 ◽

2020 ◽

Vol 132 (2) ◽

pp. 415-420 ◽

Cited By ~ 3

Author(s):

Manuri Gunawardena ◽

Jeffrey M. Rogers ◽

Marcus A. Stoodley ◽

Michael K. Morgan

Keyword(s):

Neurological Deficit ◽

Bypass Surgery ◽

Arterial Occlusion ◽

Arterial Stenosis ◽

Minimal Risk ◽

Complication Rates ◽

Intracranial Arterial Stenosis ◽

Anterior Circulation ◽

Poor Outcome ◽

Revascularization Surgery

OBJECTIVEPrevious trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust.METHODSConsecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter.RESULTSFrom 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%–6.6%).CONCLUSIONSProphylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.

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Abstract TP24: Radiological and Symptomatic Hemorrhagic Transformation Post Endovascular Thrombectomy for Both Anterior and Posterior Large Vessel Occlusion Ischemic Stroke - Insights From STAR Collaboration

Stroke ◽

10.1161/str.51.suppl_1.tp24 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Vasu Saini ◽

Reda M Chalhoub ◽

David J McCarthy ◽

Ali M Alawieh ◽

Stephanie H Chen ◽

...

Keyword(s):

Regression Model ◽

Acute Stroke ◽

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Hemorrhagic Transformation ◽

Posterior Circulation ◽

Clinical Severity ◽

Multivariable Logistic Regression Model ◽

Anterior Circulation ◽

Vessel Occlusion

Introduction: Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH. Methods: A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH. Results: 600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p<.001 vs. OR 1.04, p<.001), lower ASPECTS (OR .82, p<.001 vs. OR .83, p<.001) and higher number of thrombectomy attempts (OR 1.08, p.013 vs. OR 1.08, p .014). Patients with hyperlipidemia (OR .77, p .03 vs. OR .75, p.02) or posterior circulation strokes (OR .59, p .013 vs. OR .58, p .01) had significantly lower rates of rHT and sICH. Both rHT and sICH are independently associated with poor functional outcomes (OR .5, p<.001; OR .29, p .006). Conclusion: Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.

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Cerebral Arterial Fenestrations

Interventional Neuroradiology ◽

10.15274/inr-2014-10027 ◽

2014 ◽

Vol 20 (3) ◽

pp. 261-274 ◽

Cited By ~ 31

Author(s):

Daniel L. Cooke ◽

Charles E. Stout ◽

Warren T. Kim ◽

Akash P. Kansagra ◽

John Paul Yu ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Digital Subtraction Angiography ◽

Basilar Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Database Search ◽

Posterior Circulation ◽

Digital Subtraction ◽

Anterior Circulation ◽

Anatomic Variant ◽

Medline Database

Arterial fenestrations are an anatomic variant with indeterminate significance. Given the controversy surrounding fenestrations we sought their prevalence within our practice along with their association with other cerebrovascular anomalies. We retrospectively reviewed 10,927 patients undergoing digital subtraction angiography between 1992 and 2011. Dictated reports were searched for the terms “fenestration” or “fenestrated” with images reviewed for relevance, yielding 228 unique cases. A Medline database search from February 1964 to January 2013 generated 304 citations, 127 cases of which were selected for analysis. Cerebral arterial fenestrations were identified in 228 patients (2.1%). At least one aneurysm was noted in 60.5% of patients, with an aneurysm arising from the fenestration in 19.6% of patients. Aneurysmal subarachnoid hemorrhage or non-aneurysmal subarachnoid hemorrhage were present in 60.1% and 15.8%, respectively. For the subset of patients with an aneurysm arising directly from a fenestration relative to those patients with an aneurysm not immediately associated with a fenestration, the prevalence of aneurysmal subarachnoid hemorrhage was 66.7% vs. 58.6% (p = 0.58). Fenestrations were more often within the posterior circulation (73.2%) than the anterior circulation (24.6%), though there was no difference in the prevalence of aneurysms within these groups (61.1% vs. 60.7%, p = 1.0). Cerebral arterial fenestrations are an anatomic variant more often manifesting at the anterior communicating arterial complex and basilar artery and with no definite pathological relationship with aneurysms.

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008 Revascularisation surgery for non-moyamoya symptomatic intracranial stenosis and occlusion

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2018-anzan.8 ◽

2018 ◽

Vol 89 (6) ◽

pp. A4.3-A5

Author(s):

Marcus Stoodley ◽

Jeffrey Rogers ◽

Manuri Gunawardena ◽

Michael Morgan

Keyword(s):

Odds Ratio ◽

Bypass Surgery ◽

Surgical Complication ◽

Arterial Occlusion ◽

Graft Patency ◽

Arterial Stenosis ◽

Complication Rates ◽

Anterior Circulation ◽

Poor Outcome ◽

Stenosis And Occlusion

IntroductionPrevious trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, haemodynamic insufficiency may still be a rationale for surgery, provided it can be performed with low morbidity and that patency is robust.MethodsConsecutive patients undergoing bypass surgery for non-moyamoya symptomatic intracranial arterial stenosis and occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at six-weeks, six-months, and annually thereafter.ResultsBetween 1992 and 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were to prevent future stroke (76%) and stroke reversal (24%), with revascularisation using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurologic deficit) occurred in 8.9% of patients. The risk of poor outcome was significantly lower with arterial pedicle grafts (Odds ratio=0.15), bypass for prophylaxis against future stroke (Odds ratio=0.11), or anterior circulation bypass (Odds ratio=0.17). Over the first eight years following surgery there were no poor outcomes in the 66 cases exhibiting all three of these characteristics.ConclusionProphylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subset of individuals with haemodynamic insufficiency and ischaemic symptoms are likely to benefit from cerebral revascularisation surgery.

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Prevalence and Risk Factors Comparison of Anterior and Posterior Intracranial Arterial Stenosis

Evidence-based Complementary and Alternative Medicine ◽

10.1155/2022/7710374 ◽

2022 ◽

Vol 2022 ◽

pp. 1-8

Author(s):

Yan Zhao ◽

Beibei Liu ◽

Chunxiu Wang ◽

Shaochen Guan ◽

Chunxiao Liu ◽

...

Keyword(s):

Risk Factors ◽

Population Data ◽

Posterior Circulation ◽

Arterial Stenosis ◽

Vascular Lesions ◽

Vascular Risk ◽

Intracranial Arterial Stenosis ◽

Anterior Circulation ◽

Logistics Regression ◽

Atherosclerotic Stenosis

The prevalence and risk factors of intracranial atherosclerotic stenosis (ICAS) located in the anterior circulation (AC) and posterior circulation (PC) has been scarcely noted in the general population. We aimed to determine ICAS prevalence and risk factor profile of AC and PC in a representative population. Data were from the China Hypertension Survey of Beijing. In total, 4800 people aged 35 years or older were enrolled in this subsurvey for ICAS, and 3954 participants were eligible for analysis. ICAS was assessed by transcranial Doppler. The prevalence of ICAS in AC was much greater than that in PC (11.9% vs. 4.2%), and subjects with ICAS in PC were 3.9 years older than those with ICAS in AC. Multivariable logistics regression showed that the odds of hypertension and diabetes increased by 79% (OR: 1.79, 95% CI: 1.40–2.27) and 35% (OR: 1.35, 95% CI: 1.04–1.75) in those with AC vascular lesions and by 3.35 times (OR: 3.35, 95% CI: 2.49–4.50) and 71% (OR: 1.71, 95% CI: 1.19–2.46) in those with PC vascular lesions compared with those without vascular lesions. Most modifiable vascular risk factors for ICAS appeared to exert similar magnitudes of risk for PC to AC lesions.

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Abstract WMP4: Predictors of Functional Recovery After Thrombectomy in Posterior Circulation Stroke - Insights From the STAR Collaboration

Stroke ◽

10.1161/str.51.suppl_1.wmp4 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ali M Alawieh ◽

Maya Eid ◽

Mohammad Anadani ◽

Mithun Sattur ◽

Reda Chalhoub ◽

...

Keyword(s):

Functional Recovery ◽

Basilar Artery ◽

Functional Outcomes ◽

Posterior Circulation ◽

Stent Retriever ◽

Basilar Artery Occlusion ◽

Combined Approach ◽

Anterior Circulation ◽

Aspiration Thrombectomy ◽

Posterior Circulation Stroke

Introduction: Endovascular thrombectomy (ET) for treating acute stroke in the real-world has expanded beyond the selection criteria used in major trials, and currently includes posterior circulation strokes. Posterior circulation stroke is believed to have worse outcomes than anterior circulation stroke, and its outcomes following ET are still being studied. We explored the major determinants of functional recovery after ET for posterior circulation stroke in a large cohort of patients from the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: STAR includes patients undergoing ET for acute ischemic stroke at 12 comprehensive stroke centers in the US and globally. Data on patient demographics, technical and clinical outcomes was reviewed retrospectively from patient charts and procedure notes. Primary outcomes was the modified Ranking Score (mRS) at 90 days dichotomized into favorable (mRS 0-2) and poor outcome (mRS 3-6). Results: A total of 3850 patients were reviewed, of which 345 patients (mean age 60±14) were treated for posterior circulation stroke with predominantly basilar artery occlusion (80%). Patients were treated using aspiration thrombectomy (ADAPT, 39%), stent retriever thrombectomy (31%), combined approach (19%) or intracranial stenting (7%). The overall rate of favorable outcome was 33%. Patients with diabetes, high NIHSS on admission, and proximal occlusions had significantly higher odds of poor functional outcomes on multivariate analysis (p<0.05). Compared to ADAPT thrombectomy, significantly higher odds for poor outcomes were observed with the use of stent retriever (aOR=0.84, p<0.01) or primary combined approach (aOR=2.85, p=0.05). The advantage of ADAPT on functional recovery compared to stent retrievers persisted when regression models were limited to patients with successful recanalization, or with basilar artery occlusions. No differences in complication and hemorrhage rates were observed. Conclusions: Despite similar rates of functional recovery after ET for anterior circulation stroke between stent retriever and ADAPT, our analysis demonstrates that in posterior circulation stroke, ADAPT may lead to better functional outcomes compared to stent retriever without differences in safety profiles.

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Thrombus Histology of Basilar Artery Occlusions

Clinical Neuroradiology ◽

10.1007/s00062-020-00964-5 ◽

2020 ◽

Author(s):

M. Berndt ◽

H. Poppert ◽

K. Steiger ◽

J. Pelisek ◽

P. Oberdieck ◽

...

Keyword(s):

Basilar Artery ◽

Blood Cells ◽

White Blood Cells ◽

Posterior Circulation ◽

Anterior Circulation ◽

Mechanical Recanalization ◽

Stroke Etiology ◽

Small Incidence ◽

Underlying Pathogenesis ◽

Median Fraction

Abstract Background For patients with acute vessel occlusions of the anterior circulation histopathology of retrieved cerebral thrombi has been reported to be associated to stroke etiology. Due to the relatively small incidence of posterior circulation stroke, exclusive histopathologic analyses are missing for this subgroup. The aim of the study was to investigate thrombus histology for patients with basilar artery occlusions and uncover differences to anterior circulation clots with respect to underlying etiology. Methods A total of 59 basilar thrombi were collected during intracranial mechanical recanalization and quantitatively analyzed in terms of their relative fractions of the main constituents, e.g. fibrin/platelets (F/P), red (RBC) and white blood cells (WBC). Data were compared to histopathological analyses of 122 thrombi of the anterior circulation with respect to underlying pathogenesis. Results The composition of basilar thrombi differed significantly to thrombi of the anterior circulation with an overall higher RBC amount (median fraction in % (interquartile range):0.48 (0.37–0.69) vs. 0.37 (0.28–0.50), p < 0.001) and lower F/P count (0.45 (0.21–0.58) vs. 0.57 (0.44–0.66), p < 0.001). Basilar thrombi composition did not differ between the different etiological stroke subgroups. Conclusion The results depict a differing thrombus composition of basilar thrombi in comparison to anterior circulation clots with an overall higher amount of RBC. This may reflect different pathophysiologic processes between anterior and posterior circulation thrombogenesis, e.g. a larger proportion of appositional thrombus growth in the posterior circulation.

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