posterior circulation stroke

2. tandard settings for acute management of stroke patients: Posterior circulation
Mojtaba Khazaei, MD, fellowship of neurovascular intervention
Hamadan medical university

3. References :
• Angelika Alonso
More Case Studies in Stroke, eds. Michael G. Hennerici, Rolf
Kern, Louis R. Caplan, and Kristina Szabo.
Published by Cambridge University Press. © Cambridge
University Press 2014.

4. Clinical history
A 77-year-old woman presented with vertigo, blurred vision, and hemisensory
loss that had started 8.5 hours before admission. She reported blood pressure
levels above 200 mmHg over the last 24 hours, and the initially suspected
diagnosis was a hypertensive crisis. Lowering of blood pressure in the emergency
room, however, did not lead to symptom amelioration. Within another 2.5 hours
her symptoms progressed to a state of coma.
Two weeks before this event, she had discontinued one year of oral anticoagulation
treatment following deep vein thrombosis (DVT) and pulmonary
embolism.

5. Examination
Neurological examination on admission showed mild dysarthria and left hemisensory
loss. A few hours later, the patient had severe dysarthria, dysphagia, and progressive
loss of consciousness, together with rapidly evolving sensorimotor tetraparesis.

6. Special studies
As posterior circulation stroke was suspected, MRI was ordered and showed an
occlusion of the basilar artery with extensive hyperacute ischemic lesions in the
brainstem and cerebellum (Figure 3.1).
After confirmation of the basilar artery occlusion, we immediately started i.v.
thrombolysis with recombinant r-tPA at a dosage of 0.9 mg/kg body weight about
11 hours after symptom onset, followed by i.v. administration of the GpIIb/IIIa
antagonist tirofiban over 48 hours. Clinically, the patient regained consciousness
within six hours after thrombolysis, and the neurological deficit markedly
improved over the following days. At discharge, the patient had only slight
sensorimotor deficits, mild dysarthria, and a skew deviation.

7. Imaging findings
DWI shows extensive hyperacute ischemic lesions in the
brainstem and cerebellum. Note
the marked signal reduction of the pons in the
corresponding ADC images and only small
regions of cerebellar T2 hyperintensity on FLAIR. On
MRA, there is no signal in the basilar
artery or the left VA. The right VA appears hypoplastic.

8. Follow-up
Follow-up MRI on day 1 (Figure 3.2) displayed recanalization of the basilar
artery and ischemia in both cerebellar hemispheres. Ischemic lesions in the
brainstem were clearly improved on DWI and possibly explain her recovery.
Taking account of her medical history with DVT, we performed TEE to screen
for right-to-left shunt. TEE verified a PFO °II, with concomitant atrial septum
aneurysm. An intracardiac thrombus could not be detected.

9. Follow-up MRI on day 1
Follow-up MRI on day 1
shows recanalization of
the basilar artery and the
left VA. While
cerebellar lesions and a
territorial acute ischemic
lesion in the right PCA now
is strongly
DWI- and T2 hyperintense,
the brainstem lesions are
clearly regressive on DWI.

11. General remarks
This patient had an intracranial vertebral artery (VA) occlusion that extended into
the basilar artery. Her contralateral VA was hypoplastic. It is not entirely clear if
the occlusion was due to embolism from the PFO/atrial septal aneurysm or
formed in situ within the VA because of hypercoagulability. She had had a DVT
and had been on anticoagulants that were stopped before the stroke. The optimal
treatment of basilar artery occlusion still is a matter of debate. The primary goal is
early recanalization as it is associated with reduced mortality and improved
outcome. To date, RCTs comparing primary IVT and IAT are lacking.
A recently published prospective, observational registry failed to prove unequivocal
superiority of IAT over IVT. At present, the most discussed approach to
promote recanalization is a “bridging” concept, combining initial intravenous
treatment and subsequent intra-arterial management. However, reliable data on
safety and efficacy of combined IVT/IAT are not available yet.

12. Special remarks
The GpIIb/IIIa antagonist tirofiban has been used widely for the treatment of
acute coronary syndrome in combination with heparin and aspirin. The use of
tirofiban in the management of acute ischemic stroke within a time window of 3–
22 hours after symptom onset has been investigated recently. Treatment with
tirofiban was safe and might be favorable in long-term outcome. In basilar artery
occlusion, several case series report on combined treatment protocols with tirofiban
and IAT. General recommendations for the use of tirofiban cannot be made
thus far.

13. Posterior circulation stroke (PCS) accounts for 20–40% of ischemic stroke
In 407 patients with PCS registered in the New England Medical Center
posterior circulation registry, the most frequent symptoms were dizziness
(47%), unilateral limb weakness (41%), dysarthria (31%), headache (28%),
and nausea or vomiting (27%)
Evidence for intravenous thrombolysis and mechanical thrombectomy was
collected based on trials that mainly included patients with anterior
circulation stroke (ACS). Therefore, mechanical thrombectomy for PCS
remains understudied as compared to that for ACS. Nevertheless, most
centers perform mechanical thrombectomy in appropriate PCA cases based
on the trial results on ACS.
randomized trials for the efficacy of early decompressive craniectomy were
performed in patients with ACS, but not in those with PCS.

14. • we should be extremely careful about sudden swelling and
hemorrhagic transformation after cerebellar infarction, because they
compress the brainstem and the fourth ventricle, subsequently
resulting in hydrocephalus and brainstem herniation (malignant
cerebellar infarction)

15. Antiplatelet Therapy
• Antithrombotic therapy is an essential therapeutic strategy at every stage of stroke
management, especially for secondary prevention. Antiplatelet therapy should be
considered over anticoagulation for most patients with noncardioembolic stroke.
• Globally, aspirin, a cyclooxygenase inhibitor, and clopidogrel, a thienopyridine derivative,
are the two most-widely used oral antiplatelet agents. According to the guidelines the
combination of these two agents might be considered for initiation within 24 h of a
minor ischemic stroke or transient ischemic attack (TIA) and continued for 21 days. the
duration of administering dual antiplatelets may have to be adjusted based on the risk of
recurrent ischemic stroke and hemorrhages in individual patients.
• In the Cilostazol Stroke Prevention Study for Antiplatelet Combination (CSPS.com) trial,
the combination of cilostazol with aspirin or clopidogrel had a lower risk of ischemic
stroke recurrence and a similar risk of severe or life-threatening bleeding compared to
aspirin or clopidogrel alone in patients with high-risk noncardioembolic ischemic stroke.

16. Anticoagulation
• Generally, the proportion of cardiac embolism is smaller in PCS than in ACS
patients. In the NCVC Stroke Registry, cardioembolism accounted for 23% of PCS
and 38% of ACS
• For patients with cardioembolic stroke, anticoagulation is the first-choice
antithrombotic therapy, and anticoagulation therapeutic strategies used for PCS
are not different from those for ACS.
• Metaanalyses of the randomized controlled trials showed that NOACs are at least
as effective as warfarin for secondary stroke prevention in NVAF patients, with
around half the risk of intracranial hemorrhage.
• For using anticoagulation as secondary prevention, there are no differences in
guideline recommendations regarding the doses and timing of initiation between
patients with PCS and those with ACS. However, as huge cerebellar or occipital
infarcts can be fatal, especially when hemorrhagic transformation occurs, it
would be better to delay the initiation of oral anticoagulants in these cases.

17. Anticoagulant cont..
• patent foramen ovale (PFO)-related strokes appear to occur in the PCS more
often than in the ACS.
• Randomized trials showed that PFO closure more effectively reduces future
ischemic strokes than using antithrombotics alone in patients with high-risk PFO
(large amount of shunt, large shunt size, presence of atrial septal aneurysm).
• Nevertheless, the current evidence is not strong enough to support the use of
NOACs over aspirin in patients with PFO. Future trials are needed to determine
the role of anticoagulants, especially NOACs or dual antiplatelets, in patients with
PFO.
• vertebral artery stump syndrome is an embolic stroke resulting from the
occlusion of the stump of the vertebral artery origin. Kawano et al. identified 12
(1.4%) patients with the syndrome in 865 acute PCS patients; of these, all three
patients receiving antiplatelet therapy developed recurrent PCS during the acute
phase. Therefore, anticoagulation may be needed in these patients.

18. Blood Pressure Management
• guidelines by the American College of Cardiology/American Heart Association advocated changing
the definition of hypertension to systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg.
• hypertension control may have to be more strict in patients with PCS than in those with ACS.
• One exception would be patients in the acute stage of stroke with elevated BP and an unstable
neurological status. In particular, BP should be carefully managed in patients with hemodynamic
failure associated with severe stenosis or occlusion of the vertebra-basilar arteries. These patients
may show a fluctuating or gradually progressing neurological symptoms associated with
decreased BP. In these cases, BP should be lowered cautiously until the neurological status
becomes stable. Some patients show discontinuation of neurological progression or even
improvement of symptoms with transient, pharmacologically induced hypertension [36]. Recent
studies showed that this “induced pharmacological hypertension” is safe and feasible.
• It has also been shown that excessive BP lowering may be hazardous even in the subacute–
chronic stage if posterior fossa is hypoperfused due to severe atherosclerotic vertebrobasilar
diseases. patients with recent stroke or TIA associated with ≥50% stenosis of vertebral or basilar
arteries, those with both low blood flow and BP

19. Lipid Management

20. Thrombolysis and Thrombectomy
• Outcome data are relatively sparse for systemic thrombolysis or MT in PCS treatment
compared to ACS; however, it is well established that in PCS due to basilar artery
occlusion (BAO), the constellation of persistent vessel occlusion and moderate-tosevere
clinical deficit at presentation is uniformly associated with death or severe disability.
• endovascular therapy (with or without IV thrombolysis depending on patient eligibility)
as the standard of care for PCS due to BAO in many centers across the world.
• literature suggests that time constraints should not limit treatment for select patients
with BAO given that lack of treatment resulting in a uniformly poor outcome.
• Stroke due to occlusion of proximal large vessels in the posterior circulation, involving
the basilar artery (BA), both intracranial vertebral arteries (VAs), or one intracranial VA
with atretic contralateral VA, carries a particularly poor prognosis. When all such
untreated patients are considered, nearly 65% of patients can be left with severe deficits,
and 40% will not survive.
• Furthermore, in patients presenting with moderate-to-severe deficits, without
reperfusion therapy, rates of good outcomes can be as low as 2%.
• While the National Institute of Health Stroke Scale (NIHSS) is a less accurate measure of
the severity of the neurological deficit in PCS compared to its ACS counterpart, an NIHSS
≥10 is highly associated with death or severe disability without reperfusion therapy

21. • Unlike an ACS that may present with specific symptoms suggestive of
impairment of certain brain regions, such as hemiparesis, hemisensory
loss, hemifield cut, aphasia, or neglect, the symptoms of a PCS can be
nonspecific with dizziness, headache, or slight incoordination. These
relatively ambiguous symptoms may present as recurrent transient
ischemic attacks (TIAs), which represent the prodromal symptoms of a full-
blown BA occlusion (BAO) syndrome in 25–60% of cases, when untreated.
• Typically, the prodromal, stuttering symptoms occur in patients with
proximal BA occlusions, which are more likely to be related with
atherothrombosis whereas the abrupt, sudden symptoms associated with
mid/distal BA occlusion are more frequently associated with embolic
mechanisms .These distal embolic occlusions have higher recanalization
rates compared to their proximal, atherosclerotic counterparts

22. Historical Context
• The potential benefit of thrombolytic therapy in acute PCS was
recognized as early as 1958. In their series of 3 patients treated with
intravenous (IV) fibrinolysin, Sussman and Fitch made several
important observations.
• 1995 landmark National Institute of Neurological Disorders and
Stroke (NINDS) IV tissue plasminogen activator (t-PA) trial, which
established the benefit of t-PA in acute AIS when treated within 3 h of
last seen well (LSW) . Later, the use of IV t-PA was established out to
4.5 h from LSW.

23. Historical Context
• While IV thrombolysis remains the standard of care for AIS, its utilization in BAO is low. It
has been reported that among all patients who receive thrombolysis, only 5% have BAO
• More recently, single-arm studies have investigated outcomes in PCS treated with IV t-
PA. A retrospective study of 116 patients treated with IV t-PA over 13 years reported
rates of recanalization of 65% with trends toward favorable outcomes .Another
retrospective study reported 53% recanalization rates associated with 22% favorable
outcomes and 50% mortality.
• Basilar Artery International Cooperation Study (BASICS) group captured data on 121
patients treated with IV t-PA who achieved nearly 70% recanalization rates with 16%
mortality; however, it is worth noting that a third of these patients received rescue intra-
arterial (IA) thrombolysis .
• Rates of symptomatic intracerebral hemorrhage (sICH) in these groups ranged from 6%
to 16%, which is higher than that observed with IV t-PA treatment in ACS.
• However, two studies reported lower rates of sICH in PCS compared to ACS .
• When comparing outcomes with IV thrombolysis in PCS with ACS, a large single-center
study found a higher rate of favorable outcomes in the former than in the latter

24. Intra-Arterial Thrombolysis
• local IA thrombolysis has been used to treat AIS with thrombolytics
such as streptokinase, urokinase, or prourokinase
• Despite the increased risk of sICH, PROACT II found a significant
benefit in favor of IA therapy .The primary clinical outcome at 90 days
(modified Rankin Scale [mRS] score ≤ 2) was achieved in 40% of the
treatment group and 25% of the controls.
• several papers published have attested to the feasibility, relative
safety, and higher than expected outcomes of this approach
compared to historical controls

25. Mechanical (Nonpharmacological)
Endovascular Treatment

26. • study also demonstrated a lack of association between time to
treatment and clinical outcomes, specifically in patients with BAO
who underwent MT for BAO
• Studies have shown that patients with BAO treated more than 24 h
from LSW can have clinical outcomes and rates of sICH that are
comparable to those seen in patients treated early.
• The highly developed collateral arterial network in the posterior
circulation, reverse filling of the BA, and a layer of plasma flow
between the clot and artery wall have been proposed to maintain
brainstem viability for longer time after BAO compared to occlusions
in the anterior circulation.

27. Stroke guideline 2019

29. the Basilar Artery International Cooperation
Study (BASICS): a prospective registry study
• Posterior circulation stroke accounts for about 20% of all ischaemic
strokes. The basilar artery, which is the main vessel of the posterior
circulation, supplies most of the brainstem and occipital lobes and
part of the cerebellum and thalami. Owing to different degrees of
involvement of the brainstem, patients with acute basilar artery
occlusion (BAO) can present with symptoms that vary from isolated
cranial nerve palsies or hemiplegia to the locked-in state or coma.
Despite recent advances in the treatment of acute stroke, the rate of
death or disability associated with BAO is almost 80%.

30. BASICS method
• BASICS was a prospective, observational, international registry of consecutive patients
aged 18 years or older who presented with an acute symptomatic and radiologically confi
rmed BAO. Patients were eligible for entry if they presented with symptoms or signs
attributable to disruption of the posterior circulation, and had a BAO as confirmed by CT
angiography (CTA), magnetic resonance angiography (MRA), or conventional contrast
angiography. BAO was defined as complete obstruction of flow in the proximal, middle,
or distal portion of the basilar artery.
• Stroke severity at time of treatment was dichotomised as severe or mild to moderate.
Patients in a coma, with tetraplegia, or in a locked-in state were classed as having a
severe stroke, whereas mild-to-moderate stroke was defined as any deficit that was less
than severe.
• The primary outcome measure was poor outcome at 1 month. In view of the high risk of
death and disability in patients with BAO, poor outcome was defined as a modified
Rankin scale (mRS) score of 4 or 5 (severe disability) or death.
• three groups according to treatment: only AT (ie, received antiplatelet drugs or systemic
anticoagulation); primary IVT, including subsequent IAT; or only IAT, which comprised
thrombolysis, mechanical thrombectomy, stenting, or a combination of these
procedures.
• used an estimated time to treatment from the onset of symptoms consistent with a
clinical diagnosis of BAO, rather than the more commonly used time of onset of any
symptom to treatment.

31. BASICS study

32. BASICS study

33. BASICS study

34. BASIC study :Discussion
• Patients with a mild-to-moderate deficit more often had a poor
outcome if they were treated with IAT rather than with IVT.
comparison of IAT with IVT in these patients, the absolute increase in
the risk of death or dependency associated with IAT was 20%.
• patients with a severe deficit seemed to benefit from both IVT and
IAT; absolute risk of death or dependency was 19% (IVT) and 10%
(IAT) lower than the risk with AT. The overall rate of death or
dependency in this group was 93% in those who were treated with
only AT.
• Rates of mortality due to intracranial hemorrhage were similar after
IVT or IAT. overall rates of hemorrhage were similar to those seen in
intervention trials of anterior circulation stroke.

35. BASIC study :Discussion cont…
• study is observational and has all the limitations of a non-randomised
study.
• the often-held assumption that IAT is superior to IVT in patients with an
acute symptomatic BAO is challenged by our observations.
• our results should encourage clinicians to treat patients who have acute
symptomatic BAO and a mild-to-moderate defi cit with IVT. In case of
subsequent acute worsening, additional IAT can be considered. Patients
who present with a severe defi cit can be treated with IVT or IAT. Treatment
should be initiated as soon as possible.
• In centres that cannot provide IAT, we recommend starting IVT while the
transfer of the patient to a centre that is able to provide additional IAT if
needed is being arranged. Because the chance of a favourable response to
therapy will probably decrease with time, the initiation of IVT should not
be delayed while waiting for IAT.

36. Vertebral Artery Patency and Thrombectomy in Basilar Artery Occlusions Is There a Need for Contralateral Flow Arrest?
Tobias Boeckh-Behrens , Johannes Kaesmacher ….
Originally published7 Jan 2019. 2019;50:389–395

37. Vertebral Artery Patency and Thrombectomy in Basilar Artery Occlusions Is There a Need for Contralateral Flow Arrest?
Tobias Boeckh-Behrens , Johannes Kaesmacher ….
Originally published7 Jan 2019. 2019;50:389–395
• The main finding of this study is that full recanalization success
is strongly and independently associated with a hypoplastic or
aplastic contralateral VA (contralateral low flow), shorter clot
length, and pretreatment with intravenous tPA. The finding of a
substantial impact of antegrade flow effects on recanalization
success and the risk of distal embolization is in line with
previous findings derived from anterior circulation large vessel
occlusion cohorts and in vitro studies evaluating the impact of
antegrade flow modulation.