Double Oxymoron Crisis: Posterior Circulation Intracranial Bleeding with Anterior Circulation Ischemic Stroke—A Management Dilemma

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

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Abstract TP400: The Differences of Vessel Wall Features Between the Anterior and Posterior Brain Arteries Detected by High Resolution Magnetic Resonance Imaging in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp400 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Xiangyan Chen ◽

Lu Zheng ◽

Jia LI ◽

Wenjie Yang

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

High Resolution ◽

Acute Ischemic Stroke ◽

Vessel Wall ◽

Posterior Circulation ◽

Intraplaque Hemorrhage ◽

Resonance Imaging ◽

Anterior Circulation

Backgrounds: The purpose of this study was to investigate vessel wall features visualization by high resolution magnetic resonance imaging (HRMRI) in a series of ischemic stroke patients and to identify differences between lesions in the anterior and posterior circulation. Methods: We consecutively recruited Chinese patients with acute ischemic stroke or transient ischemic attack from 2016 to 2018. All patients were scanned at 3T magnetic resonance imaging. We evaluated pre-and post-contrast cross-sectional views of M1 and M2 segments of middle cerebral arteries (MCAs), basilar arteries (BA) and V4 segments of vertebral arteries (VAs). Results: A total of 74 patients (males 52.3%; median age 62 years old) were included in this study, among which, 234 lesions were identified on HRMRI, including 117 MCA lesions, 26 BA lesions, and 91 VA lesions. The sensitivity and specificity of MRA for diagnosing stenosis in anterior circulation were 89.3% (95% CI, 81.8%- 94.2%) and 50.0 (95% CI, 9.2%- 90.8%). The sensitivity and specificity of MRA for diagnosing stenosis in posterior circulation were 73.2% (95% CI, 63.9%- 80.9%) and 40.0 (95% CI, 7.3%- 83.0%). VA had a significantly higher contrast enhancement index (43.71± 7.74, p <0.016) than MCA (23.32± 2.46) or BA (22.69± 5.31) . Anterior circulation plaques had higher degree of stenosis (anterior versus posterior: 68.5% vs. 62.9%, p =0.036), more eccentric distribution (anterior versus posterior: 70.1% versus 53.8%, p =0.015) and higher rate of intraplaque hemorrhage (anterior versus posterior: 17.1% versus 7.7%, p =0.046). The plaques in posterior circulation had a thicker lesion wall (posterior versus anterior 16.58± 8.25 mm 2 vs. 9.10± 4.07 mm 2 , p <0.001) and higher enhancement index (posterior versus anterior 39.04± 8.50 vs. 23.32± 2.46, p <0.001) than the plaques in anterior circulation. Conclusions: The lesions in posterior circulations could be obscure on MRA. The area stenosis, intraplaque hemorrhage and enhancement index differed between circulations.

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Abstract TP361: Recreational Drug Use and Arterial Ischemic Stroke in a Pediatric Cohort

Stroke ◽

10.1161/str.51.suppl_1.tp361 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ishvinder Bhathal ◽

Tazeen Qureshi ◽

Mahendranath Moharir ◽

Daune MacGregor ◽

Elizabeth Pulcine ◽

...

Keyword(s):

Ischemic Stroke ◽

Drug Use ◽

Tertiary Care ◽

Case Series ◽

Posterior Circulation ◽

Recreational Drug ◽

Arterial Ischemic Stroke ◽

Anterior Circulation ◽

Recreational Drug Use ◽

The Impact

Background: Existing literature reports an association between recreational drug use and arterial ischemic stroke (AIS) in adults. Due to recent trends in legalization and concerns regarding the impact of drugs on the developing brain, there is an urgent need for increased awareness of recreational drug use as a risk factor for AIS in childhood. Purpose: To increase awareness of an association between AIS and recreational drug use in a pediatric cohort. Methods: We conducted a retrospective chart review of a consecutive cohort of patients at a tertiary care pediatric center diagnosed with AIS in the context of recreational drug use between 2008-2017. Drug use was confirmed using toxicology testing and clinical history. Demographic, clinical and radiological data were collected. Pediatric Stroke Outcome Measure scores (PSOM) were obtained from an institutional Stroke Registry. Results: Three males and one female were included in the study. Mean age at stroke presentation was 16.3 years (range 16-17 years). Three children presented with focal neurologic deficit and one with new onset seizure. Drug use for each patient was described as follows: Patient A - Marijuana; Patient B - Oxybutynin, Fluoxetine and unidentified compound; Patient C - Marijuana and Amphetamine; Patient D - Marijuana and alcohol. MRI demonstrated diffusion restriction in the anterior circulation in two children, anterior and posterior circulation in one child, and bilateral posterior circulation in one child also found to have a remote AIS. Vascular findings included: Patient A - normal; Patient B and C - right anterior circulation arteriopathy; Patient D - posterior circulation arteriopathy and bilateral vessel wall enhancement. ECHO and pro-thrombotic results were non-contributory. However, one patient required PFO closure. PSOM scores indicated mild-moderate disability initially and moderate disability at follow-up for three of four patients. Conclusions: This case series describes an association between recreational drug use and AIS in adolescents. We are unable to comment on the incidence of AIS related to drug use from our cohort. However, our data highlights a need for public health strategies that acknowledge AIS as a potential consequence of recreational drug use in adolescents.

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Diagnosis of DWI-negative acute ischemic stroke

Neurology ◽

10.1212/wnl.0000000000004120 ◽

2017 ◽

Vol 89 (3) ◽

pp. 256-262 ◽

Cited By ~ 39

Author(s):

Brian L. Edlow ◽

Shelley Hurwitz ◽

Jonathan A. Edlow

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Diagnosis ◽

Clinical Characteristics ◽

Meta Analysis ◽

Reperfusion Therapy ◽

Posterior Circulation ◽

Anterior Circulation ◽

Ovid Medline ◽

Level Data

Objective:To determine the prevalence of diffusion-weighted imaging (DWI)–negative acute ischemic stroke (AIS) and to identify clinical characteristics of patients with DWI-negative AIS.Methods:We systematically searched PubMed and Ovid/MEDLINE for relevant studies between 1992, the year that the DWI sequence entered clinical practice, and 2016. Studies were included based upon enrollment of consecutive patients presenting with a clinical diagnosis of AIS prior to imaging. Meta-analysis was performed to synthesize study-level data, estimate DWI-negative stroke prevalence, and estimate the odds ratios (ORs) for clinical characteristics associated with DWI-negative stroke.Results:Twelve articles including 3,236 AIS patients were included. The meta-analytic synthesis yielded a pooled prevalence of DWI-negative AIS of 6.8%, 95% confidence interval (CI) 4.9–9.3. In the 5 studies that reported proportion data for DWI-negative and DWI-positive AIS based on the ischemic vascular territory (n = 1,023 AIS patients), DWI-negative stroke was strongly associated with posterior circulation ischemia, as determined by clinical diagnosis at hospital discharge or repeat imaging (OR 5.1, 95% CI 2.3–11.6, p < 0.001).Conclusions:A small but significant percentage of patients with AIS have a negative DWI scan. Patients with neurologic deficits consistent with posterior circulation ischemia have 5 times the odds of having a negative DWI scan compared to patients with anterior circulation ischemia. AIS remains a clinical diagnosis and urgent reperfusion therapy should be considered even when an initial DWI scan is negative.

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Cohort study of THRIVE predicting adverse outcomes in acute ischemic stroke of the anterior circulation and posterior circulation after 3 months and 1 year of follow-up

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2021.12.004 ◽

2022 ◽

Vol 96 ◽

pp. 33-37

Author(s):

Li-Li Chen ◽

Shuang-mei Yan ◽

Wen-Ting Wang ◽

Sai Zhang ◽

Hui-Miao Liu ◽

...

Keyword(s):

Cohort Study ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Adverse Outcomes ◽

Posterior Circulation ◽

Anterior Circulation

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Comparative study of posterior and anterior circulation stroke in childhood

Neurology ◽

10.1212/wnl.0000000000008837 ◽

2019 ◽

Vol 94 (4) ◽

pp. e337-e344 ◽

Cited By ~ 1

Author(s):

Barbara Goeggel Simonetti ◽

Mubeen F. Rafay ◽

Melissa Chung ◽

Warren D. Lo ◽

Lauren A. Beslow ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Presentation ◽

Case Fatality ◽

Posterior Circulation ◽

Stroke Severity ◽

Neurologic Examination ◽

Arterial Ischemic Stroke ◽

Anterior Circulation ◽

Multicenter Observational Study ◽

International Multicenter

ObjectiveTo compare risk factors, clinical presentation, and outcomes after posterior circulation arterial ischemic stroke (PCAIS) and anterior circulation arterial ischemic stroke (ACAIS) in neonates and children.MethodsIn this international multicenter observational study including neonates and children up to 18 years of age with arterial ischemic stroke (AIS), we compared clinical and radiologic features according to stroke location.ResultsOf 2,768 AIS cases, 507 (18%) were located in the posterior circulation, 1,931 (70%) in the anterior circulation, and 330 (12%) involved both. PCAIS was less frequent in neonates compared to children (8.8% vs 22%, p < 0.001). Children with PCAIS were older than children with ACAIS (median age 7.8 [interquartile range (IQR) 3.1–14] vs 5.1 [IQR 1.5–12] years, p < 0.001), and more often presented with headache (54% vs 32%, p < 0.001) and a lower Pediatric NIH Stroke Scale score (4 [IQR 2–8] vs 8 [IQR 3–13], p = 0.001). Cervicocephalic artery dissections (CCAD) were more frequent (20% vs 8.5%, p < 0.001), while cardioembolic strokes were less frequent (19% vs 32%, p < 0.001) in PCAIS. Case fatality rates were equal in both groups (2.9%). PCAIS survivors had a better outcome (normal neurologic examination at hospital discharge in 29% vs 21%, p = 0.002) than ACAIS survivors, although this trend was only observed in children and not in neonates.ConclusionPCAIS is less common than ACAIS in both neonates and children. Children with PCAIS are older and have a higher rate of CCAD, lower clinical stroke severity, and better outcome than children with ACAIS.

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Intra-arterial Thrombectomy with Stent Retriever for Acute Ischemic Stroke – a Retrospective, Single-centered Study from Brazil

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0037-1607062 ◽

2017 ◽

Vol 36 (04) ◽

pp. 213-216

Author(s):

Luana Gatto ◽

Viviane Zétola ◽

Zeferino Demartini Junior ◽

Fábio Nascimento ◽

Gelson Koppe

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mean Value ◽

Posterior Circulation ◽

Stent Retriever ◽

National Institutes Of Health ◽

Initial Experience ◽

Modified Rankin Scale ◽

Anterior Circulation ◽

The Mean

Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retriever for acute ischemic stroke. Methods We conducted a retrospective review of patients with acute ischemic stroke who underwent IAT from September 2010 to August 2016. Results Forty-one patients were included; mean age was 57 years (range: 29–85), and 54% were women. There were 32 anterior circulation occlusions, and 11 posterior circulation occlusions. The mean value of the National Institutes of Health Stroke Scale (NIHSS) upon admission (available in 9/41 patients) was 14 (range: 6–20). Nineteen patients had favorable outcomes (modified Rankin Scale [mRS]: 0–2 at 6 months), and 22 had unfavorable outcomes (mRS: 3–6 at 6 months). The mortality rate was 37% (15/41). Favorable outcomes were associated with revascularization within the first 360 minutes of the onset of symptoms (p = 0.000001), and satisfactory revascularization (thrombolysis in cerebral infarction [TICI] scale: 2b or 3) (p = 0.0018). Conclusion It is of paramount importance to educate stroke teams on the benefits of IAT for acute ischemic stroke and the population on identifying stroke and seeking immediate care following symptom onset.

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Reclassifications of ischemic stroke patterns due to variants of the Circle of Willis

International Journal of Stroke ◽

10.1177/17474930211048381 ◽

2021 ◽

pp. 174749302110483

Author(s):

Ida Rangus ◽

Lennart S Milles ◽

Ivana Galinovic ◽

Kersten Villringer ◽

Heinrich J Audebert ◽

...

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Circle Of Willis ◽

Posterior Circulation ◽

Correct Identification ◽

Anterior Circulation ◽

Ischemic Lesion

Background Variants of the Circle of Willis (vCoW) may impede correct identification of ischemic lesion patterns and stroke etiology. We assessed reclassifications of ischemic lesion patterns due to vCoW. Methods We analyzed vCoW in patients with acute ischemic stroke from the 1000+ study using time-of-flight magnetic resonance angiography (TOF MRA) of intracranial arteries. We assessed A1 segment agenesis or hypoplasia in the anterior circulation and fetal posterior cerebral artery in the posterior circulation. Stroke patterns were classified as one or more-than-one territory stroke pattern. We examined associations between vCoW and stroke patterns and the frequency of reclassifications of stroke patterns due to vCoW. Results Of 1000 patients, 991 had evaluable magnetic resonance angiography. At least one vCoW was present in 37.1%. VCoW were more common in the posterior than in the anterior circulation (33.3% vs. 6.7%). Of 238 patients initially thought to have a more-than-one territory stroke pattern, 20 (8.4%) had to be reclassified to a one territory stroke pattern after considering vCoW. All these patients had fetal posterior cerebral artery and six (30%) additionally had carotid artery disease. Of 753 patients initially presumed to have a one-territory stroke pattern, four (0.5%) were reclassified as having more-than-one territory pattern. Conclusions VCoW are present in about one in three stroke patients and more common in the posterior circulation. Reclassifications of stroke lesion patterns due to vCoW occurred predominantly in the posterior circulation with fetal posterior cerebral artery mimicking multiple territory stroke pattern. Considering vCoW in these cases may uncover symptomatic carotid disease.

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Prevalence of Intracranial Artery Stenosis in Patients with Acute Ischemic Stroke in a Tertiary Care Hospital of China

Journal of Nepal Medical Association ◽

10.31729/jnma.5201 ◽

2020 ◽

Vol 58 (229) ◽

Author(s):

Sandip Kumar Jaiswal ◽

Yan Fuling ◽

Min Li

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Posterior Circulation ◽

Artery Stenosis ◽

Care Hospital ◽

Intracranial Artery ◽

Anterior Circulation ◽

Intracranial Artery Stenosis

Introduction: Intracranial artery stenosis is the most common cause of acute ischemic stroke, especially among people in Asia. About its epidemiology, however little is understood. The goal of our research is to establish the prevalence of intracranial artery stenosis in patients with acute ischemic stroke in a tertiary care hospital. Methods: A descriptive cross-sectional study was done in 1006 acute ischemic stroke patients at Affiliated Zhongda Hospital, School of Medicine, Southeast University China from May 2018 to May 2019. Ethical approval was taken from the Ethical review committee of the institution. A convenient sampling method was done. Intracranial artery stenosis was diagnosed when evidence of acute ischemic stroke was found in the territory of approximately 2 50% stenosis identified by Transcranial Doppler ultrasound and confirmed by magnetic resonance angiography or computed tomography. Statistical analysis was done using the Statistical Package for the Social Sciences version 20. Results: The prevalence of intracranial artery stenosis was found in 331 (32.90%) patients at 95% Confidence interval (0.24-0.42%). Among 331 cases the anterior circulation artery stenosis was present on 201 (19.98%) patients, followed by posterior circulation artery stenosis on 80 (7.95%) patients, then anterior plus posterior circulation artery stenosis on 50 (4.97%) patients. Conclusions: Intracranial artery stenosis is one of the most causes of acute ischemic stroke in China. The proportion of anterior circulation artery stenosis was higher than that in the posterior circulation.

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Aspiration Versus Stent Retriever Thrombectomy for Posterior Circulation Stroke

Stroke ◽

10.1161/strokeaha.121.034926 ◽

2021 ◽

Author(s):

Marie Louise E. Bernsen ◽

Agnetha A.E. Bruggeman ◽

Josje Brouwer ◽

Bart J. Emmer ◽

Charles B.L.M. Majoie ◽

...

Keyword(s):

Ischemic Stroke ◽

The Netherlands ◽

Endovascular Treatment ◽

Functional Outcome ◽

Posterior Circulation ◽

Stent Retriever ◽

Modified Rankin Scale ◽

First Line ◽

Anterior Circulation ◽

Posterior Circulation Stroke

Background and Purpose: Whereas a clear benefit of endovascular treatment for anterior circulation stroke has been established, randomized trials assessing the posterior circulation have failed to show efficacy. Previous studies in anterior circulation stroke suggest that advanced thrombectomy devices were of great importance in achieving clinical benefit. Little is known about the effect of thrombectomy techniques on outcomes in posterior circulation stroke. In this study, we compare first-line strategy of direct aspiration to stent retriever thrombectomy for posterior circulation stroke. Methods: We analyzed data of patients with a posterior circulation stroke who were included in the Multicentre Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry between March 2014 and December 2018, a prospective, nationwide study, in which data were collected from consecutive patients who underwent endovascular treatment for ischemic stroke in the Netherlands. We compared patients who underwent first-line aspiration versus stent retriever thrombectomy. Primary outcome was functional outcome according to the modified Rankin Scale. Secondary outcomes were reperfusion grade, complication rate, and procedure duration. Associations between thrombectomy technique and outcome measures were estimated with multivariable ordinal logistic regression analyses. Results: Overall, 71 of 205 patients (35%) were treated with aspiration, and 134 (65%) with stent retriever thrombectomy. Patients in the aspiration group had a lower pc-ASPECTS on baseline computed tomography, and general anesthesia was more often applied in this group. First-line aspiration was associated with better functional outcome compared with stent retriever thrombectomy (adjusted common odds ratio for a 1-point improvement on the modified Rankin Scale 1.94 [95% CI, 1.03–3.65]). Successful reperfusion (extended Thrombolysis in Cerebral Infarction ≥2B) was achieved more often with aspiration (87% versus 73%, P =0.03). Symptomatic hemorrhage rates were comparable (3% versus 4%). Procedure times were shorter in the aspiration group (49 versus 69 minutes P <0.001). Conclusions: In this retrospective nonrandomized cohort study, our findings suggest that first-line aspiration is associated with a shorter procedure time, better reperfusion, and better clinical outcome than stent retriever thrombectomy in patients with ischemic stroke based on large vessel occlusion in the posterior circulation.

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