Long-term outcome in posterior cerebral artery stroke

Intravenous thrombolysis for ischemic stroke in the posterior circulation: A systematic review and meta-analysis

OBJECTIVES

Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis.

METHODS

A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R.

RESULTS

Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively).

CONCLUSIONS

IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window.

Endovascular therapy for posterior cerebral artery occlusion: systematic review with meta-analysis

Endovascular therapy (EVT) is a highly effective stroke treatment, but trials validating this intervention did not include patients with posterior cerebral artery (PCA) occlusion. The aim of this systematic review with meta-analysis was to assess the efficacy and safety of EVT for acute PCA occlusion. PubMed, Scopus, ISI, and CENTRAL were searched for studies assessing EVT in adult patients with PCA occlusion. Outcomes of interest were recanalization, symptomatic intracerebral haemorrhage (sICH), mortality, functional independence, and excellent functional outcome at 90 days. Frequencies and odds ratios (ORs) were pooled using random effect models and heterogeneity was measured using the I2 statistic and explored by means of meta-regression. Fifteen studies were included, all observational. Recanalization rates were high [81%, 95% CI (73-88%)] and sICH rates low [2%, 95% CI (1-4%)]. Heterogeneity was high for recanalization (I2 = 80%) but not for sICH, and not accounted for by any of the moderators tested. Compared to best medical treatment, EVT was associated with higher chances of sICH [OR = 2.04, 95% CI (1.12-3.71)] and no effect in functional independence [OR = 0.98, 95% CI (0.63-1.54)], with a tendency to higher chances of excellent functional outcome [OR = 1.29, 95% CI (0.90-1.86)] and mortality [OR = 1.56, 95% CI (0.84-2.90)]. EVT for acute PCA occlusion is technically feasible but associated with higher chance of sICH. There is no evidence to support this treatment to achieve higher rates of functional independence, but other gains that can impact patients' quality of life cannot be excluded. More studies are required with robust design, better patient selection, and comprehensive outcome evaluation.

Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO.

METHODS

We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model.

RESULTS

Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29).

CONCLUSIONS

In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.

Demographics, Risk Factors, and Etiology of Posterior Cerebral Artery Stroke Causing Homonymous Hemianopia

BACKGROUND

Posterior cerebral artery (PCA) strokes account for up to 10% of all ischemic strokes, often presenting with homonymous hemianopia. The proportion of these strokes attributed to various etiologies varies widely in previously published studies, owing largely to differing patient populations, definitions of stroke pathogenesis, and vascular territories involved. The Causative Classification System (CCS), an automated version of the Stop Stroke Study (SSS) Trial of Org 10,172 in Acute Stroke Treatment (TOAST) system, allows for a more rigorous assignment of stroke etiology.

METHODS

We excerpted clinical and imaging data on 85 patients who had PCA stroke with homonymous hemianopia examined at the University of Michigan. We compared the stroke risk factor profile of our PCA cohort with that of 135 patients with stroke in the distribution of the internal carotid artery (ICA) and middle cerebral artery (MCA) in an unpublished University of Michigan registry. We applied the CCS web-based calculator to our PCA cohort to determine stroke etiology.

RESULTS

In our PCA cohort, 80.0% had at least 2 conventional stroke risk factors and 30.6% had 4 risk factors, most commonly systemic hypertension. The risk factor profile of our PCA cohort resembled that of our ICA/MCA cohort except that the mean age of our PCA cohort was more than a decade younger and had a significantly lower frequency of atrial fibrillation (AF) than our ICA/MCA cohort. In nearly half of the patients with AF in our PCA cohort, AF was diagnosed after the stroke. Among stroke etiologies in our PCA cohort, 40.0% were of undetermined cause, 30.6% were from cardioaortic embolism, 17.6% were from other determined causes, and only 11.8% were from supra-aortic large artery atherosclerosis. Strokes after endovascular or surgical interventions were prominent among other determined causes.

CONCLUSIONS

Most patients in our PCA cohort had multiple conventional stroke risk factors, a finding not previously documented. Mean age at stroke onset and AF frequency were lower than in our ICA/MCA cohort, in agreement with previous studies. As some other studies have found, nearly 1/3 of strokes were attributed to cardioaortic embolism. Within that group, AF was often a poststroke diagnosis, a finding not previously highlighted. Compared with earlier studies, a relatively high portion of strokes were of undetermined etiology and of other determined etiologies, including stroke after endovascular or surgical interventions. Supra-aortic large artery atherosclerosis was a relatively uncommon explanation for stroke.

What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke?

Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.

Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction

BACKGROUND

The incidence, risk factors, and pathogenesis of early neurological deterioration (END) in posterior circulation stroke are still unclear. In this study, we aimed to determine the risk factors and prognosis of END in patients with acute posterior circulation cerebral infarction.

METHODS

Acute posterior circulation ischemic stroke patients who had completed neuroimaging within 72 h of onset were selected from a prospective registry study Demographic characteristics, physiological data, medical history, laboratory data, in-hospital evaluation, neurological severity and TOAST classification, treatment, and the modified Rankin Scale (mRS) score of patients were assessed. Early neurological deterioration was defined as an increase of 2 points in the National Institutes of Health Stroke Scale score between the baseline and 72 h evaluation. Favorable and poor outcomes were defined as mRSs of 02 and≥ 3, respectively, at 3 months. The incidence and risk factors were evaluated by univariate and multivariate regression analysis (step-back method).

RESULTS

The analysis included 455 subjects with an acute posterior circulation non-cardiac ischemic stroke, 330 (72.53 %) of them male, with an average age of 63.12 ( ± 10.14) years and with 47 (10.33 %) having END. The results of univariate and multivariate logistic regression analysis showed that BATMAN scores ≥ 5 (OR: 0.1, 95 % CI: 0.02-0.53, P < 0.01), large artery atherosclerosis (OR: 11.55, 95 % CI: 4.18-31.93, P < 0.01), vascular stenosis > 50 % (OR: 2.44, 95 % CI: 1.1-5.42, P = 0.029), reperfusion therapy (OR: 4.21, 95 % CI: 1.66-10.64, P < 0.01), and the distribution of pontine lesions (OR: 5.66, 95 % CI: 2.39-13.44, P < 0.01) were significantly associated with END. Patients with END had a lower rate of favorable outcomes at discharge and long-term follow-up (P < 0.001), regardless of whether they received reperfusion therapy.

CONCLUSION

The lesion distribution of the pons, the progression of temporo-occipital lobe lesions, and large arterial atherosclerosis are independent risk factors of END that might predict a poor short- and long-term prognosis.

Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature

BACKGROUND

Acute isolated posterior cerebral artery (PCA) occlusions account for 5-10% of all ischemic events. Due to peculiar patient presentation, the potential benefit of mechanical thrombectomy (MT) remains controversial. We evaluated the safety, feasibility, and effectiveness of MT in our patients and compared our results with the literature review conducted.

METHODS

Charts were reviewed retrospectively for consecutive patients diagnosed with acute PCA stroke who underwent MT. Demographics, procedural, and follow-up details were noted. For the literature review, a systematic search of PubMed, MEDLINE, and EMBASE databases was conducted for the keywords "posterior cerebral artery" and "thrombectomy" for articles published between January 1, 2010 and June 30, 2021. Estimated rates for recanalization, favorable outcomes (modified Rankin Scale [mRS] score 0-2), symptomatic intracerebral hemorrhage (sICH), and mortality were extracted.

RESULTS

Our cohort included 21 patients. Mean age was 71.2 years (standard deviation [SD] ± 10.2). Median National Institutes of Health Stroke Scale (NIHSS) presentation score was 9 (interquartile range [IQR] 5-15), with visual symptoms reported in 12(57.1%) patients. Overall, final modified thrombolysis in cerebral infarction (mTICI) 2b-3 was achieved in 17 patients (80.9%) with first-pass mTICI 2b-3 attained in 8 (38.1%). Postprocedure sICH occurred in 1 (4.8%) patient. Fifteen (71.4%) patients had a 0-2 mRS score at 90 days. Visual symptoms resolved in 10 of 12(83.3%) patients. Mortality occurred in 2 (9.5%) patients. For the systematic review, cohorts from 4 articles plus ours were included, totaling 222 patients. The estimated rate of successful recanalization was 85.25% (95% confidence interval[CI], 73.05%-97.45%), sICH was 3.60% (95% CI, 1.11%-6.09%), and mortality was 10.51% (95% CI, 5.88%-15.15%).

CONCLUSION

The results of our series and systematic review indicate MT as a potentially safe and effective treatment modality for acute PCA stroke. These results also indicate that patient selection and assessment may be the key in obtaining favorable outcomes.

Thrombectomy of symptomatic isolated occlusions of posterior cerebral arteries in segment P1 and P2 in acute stroke treatment

BACKGROUND

Interventional stroke treatments for occlusions of the posterior circulation are established procedures. However, there are limited data on the treatment of isolated symptomatic P1 and P2 occlusions, which we have examined in this study.

PURPOSE

To investigate the mechanical thrombectomy of distal posterior occlusions.

MATERIAL AND METHODS

Retrospectively, data from patients with isolated P1 and P2 occlusions treated with MT were evaluated. Successful reperfusions have been defined as modified thrombolysis in cerebral infarct (mTICI) Grade 2b-3. A good clinical outcome was defined as a 90-day modified Rankin score 0-2.

RESULTS

All 79 treated patients were primarily aspirated. Stent retrievers were used secondarily in nine patients. Successful reperfusion was achieved in 95% of patients. Of the patients, 57% had a favorable clinical outcome after 90 days.

CONCLUSION

Mechanical thrombectomy with first line aspiration of symptomatic P1 and P2 occlusions is a safe and effective procedure.

Endovascular Therapy versus No Endovascular Therapy in Patients receiving Best Medical Management for Acute Isolated Occlusion of the Posterior Cerebral Artery: Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Endovascular therapy (EVT) is increasingly reported for treatment of isolated posterior cerebral artery (PCA) occlusions although its clinical benefit remains uncertain. This study-level meta-analysis investigated functional outcome and safety of EVT and best medical management (BMM) compared to BMM for treatment of PCA occlusion stroke.

METHODS

We conducted a literature search in PubMed, Web of Science and Embase for articles reporting patients with isolated PCA occlusion stroke treated with EVT+BMM or BMM including intravenous thrombolysis. There were no randomized trials and all studies were retrospective. Primary outcome was a modified Rankin Scale score of 0-2 at 3 months; safety outcomes included mortality rate and incidence of symptomatic intracranial hemorrhage.

RESULTS

Twelve articles with a total of 679 patients were included in the meta-analysis consisting of 338 patients with EVT+BMM and 341 patients receiving BMM alone. Good functional outcome at 3 months was achieved in 58.0% [95% confidence interval (CI) 43.83-70.95] of patients with EVT+BMM and 48.1% [95% CI 40.35-55.92] of patients with BMM with respective mortality rates of 12.6% [7.30-20.93] and 12.3% [8.64-17.33]. Symptomatic intracranial hemorrhage occurred in 4.2% [95% CI 2.47-7.03] of patients with EVT+BMM and 3.2% [95% CI 1.75-5.92] of patients with BMM. Comparative analyses were performed of publications reporting both treatments and demonstrated no significant differences.

CONCLUSIONS

The results demonstrate that EVT represents a safe treatment for patients with isolated PCA occlusion stroke. There were no differences in clinical or safety outcomes between treatments, supporting randomization of future patients into distal vessel occlusion trials.

Mechanical thrombectomy for acute posterior cerebral artery stroke; Feasibility and predictors of outcome

PURPOSE

The territorial involvement and the clinical benefit of endovascular therapy (EVT) of the posterior cerebral artery (PCA) occlusion may vary between patients. The purpose of this study was to investigate the feasibility of mechanical thrombectomy (MT) in isolated posterior cerebral artery occlusions (IPCAOs) and the prognostic factors of EVT.

METHODS

Forty-eight patients with acute PCA occlusion who underwent EVT between Mar 2008 and Apr 2021 from 2 tertiary centers were retrospectively analyzed. Clinical characteristics, imaging and perfusion abnormalities, and angiographic and clinical outcomes were analyzed. Ischemic changes were assessed with the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS). Perfusion abnormalities were assessed using automated software for Tmax volume measurement and identification of Tmax involved in PCA eloquent areas.

RESULTS

The IPCAO sites were P1 (n = 17) and P2 (n = 31). Overall successful recanalization (mTICI 2b/3) was achieved in 68.8% (33/48) and excellent outcome (90-day mRS 0-1) in 52.1% (25/48) of the patients. Excellent/non-excellent outcome was associated with male sex (p = 0.036), admission NIHSS (p = 0.002), pc-ASPECTS (p = 0.035), Tmax > 6 s involvement of the midbrain-thalamus (p = 0.008), first-line stent-retriever thrombectomy (p = 0.036), complete recanalization (p = 0.009), and modified first pass effect (FPE, p = 0.047). Tmax>6 s involvement of the midbrain-thalamus was an independent predictor for non-excellent outcome on multivariable analysis.

CONCLUSION

Acute stroke from IPCAO may be successfully treated with EVT. Tmax > 6 s involvement of the midbrain-thalamus on perfusion imaging may be a predictor for clinical outcome.

Mechanical thrombectomy versus intravenous alteplase alone in acute isolated posterior cerebral artery occlusion: a systematic review

BACKGROUND

Acute isolated posterior cerebral artery occlusions (aPCAOs) were excluded or under-represented in major randomized trials of mechanical thrombectomy (MT). The benefit of MT in comparison to intravenous tissue plasminogen activator (alteplase; IV-tPA) alone in these patients remains controversial and uncertain.

METHODS

We performed a systematic search of PubMed, MEDLINE, and EMBASE databases for articles comparing MT with or without bridging IV-tPA and IV-tPA alone for aPCAO using keywords ('posterior cerebral artery', 'thrombolysis' and 'thrombectomy') with Boolean operators. Extracted data from patients reported in the studies were pooled into groups (MT vs IV-tPA alone) for comparison. Estimated rates for favorable outcome (modified Rankin scale score 0-2), symptomatic intracranial hemorrhage (sICH), and mortality were extracted.

RESULTS

Seven articles (201 MT patients, 64 IV-tPA) were included, all retrospective. There was no statistically significant difference between pooled groups in median age, median presentation National Institutes of Health Stroke Scale (NIHSS) score, PCAO segment, and median time from symptom onset to puncture or needle. The recanalization rate was significantly higher in the MT group than the IV-tPA group (85.6% vs 53.1%, p<0.00001). Odds ratios for favorable outcome (OR 1.5, 95% CI 0.8 to 2.5), sICH (OR 1.1, 95% CI 0.2 to 5.5), and mortality (OR 1.4, 95% CI 0.5 to 3.6) did not significantly favor any modality.

CONCLUSIONS

We found no significant differences in odds of favorable outcome, sICH, and mortality in MT and IV-tPA in comparable aPCAO patients, despite superior MT recanalization rates. Equipoise remains regarding the optimal treatment modality for these patients.

Left Ventricular Noncompaction Cardiomyopathy as a Potential Cause of Bilateral Posterior Cerebral Artery Stroke - a Rare and Unique Clinical Occurrence

Patient: Male, 63-year-old

Final Diagnosis: Occurrence of bilateral PCA infarcts with LVNC cardiomyopathy

Symptoms: Acute vision loss in both eyes • dysarthria

Medication: —

Clinical Procedure: Emergency endovascular thrombectomy

Specialty: Neurology

Occipital intracerebral hemorrhage-clinical characteristics, outcome, and post-ICH epilepsy

OBJECTIVES

Posterior location affects the clinical presentation and outcome of ischemic stroke, but little is known about occipital intracerebral hemorrhage (ICH). We studied non-traumatic occipital ICH phenotype, outcome, and post-ICH epilepsy.

MATERIALS AND METHODS

Occipital ICH patients were retrospectively identified from the Helsinki ICH Study registry of 1013 consecutive ICH patients treated in our tertiary center in 2005-2010. They were compared to non-occipital ICH patients to evaluate the effect of location on functional outcome at discharge (dichotomized modified Rankin Scale, mRS), 3- and 12-month mortality, and incidence of epilepsy.

RESULTS

We found 19 occipital ICH patients (5.3% of lobar and 1.9% of all ICH). Compared to non-occipital lobar ICHs, they were younger (median age 63 vs 71 years, P = .007) and had lower National Institutes of Health Stroke Scale on admission (1 vs 8, P < .001), smaller hematoma volume (6.3 vs 17.7 ML, P = .008), and more frequently structural etiology underlying the ICH (26% vs 7%, P = .01). Mortality at both 3 and 12 months was 6%, whereas 84% reached favorable outcome (mRS 0-2) at discharge. Occipital location was associated with favorable outcome at discharge in lobar ICH (OR 11.02, 95% CI 1.55-78.20). Incidence of post-ICH epilepsy (median follow-up 2.7 years) was 18%, equaling to that of non-occipital lobar ICH.

CONCLUSIONS

Occipital ICH patients are younger, have less severe clinical presentation, smaller hematoma volume, more often structural etiology, and better outcome than other ICH patients. They exhibit a similar risk of epilepsy as non-occipital ICHs.

Feasibility and safety of thrombectomy for isolated occlusions of the posterior cerebral artery: a multicenter experience and systematic literature review

BACKGROUND

Substantial clinical evidence supporting the benefit of mechanical thrombectomy (MT) for distal occlusions within the posterior circulation is still missing. This study aims to investigate the procedural feasibility and safety of MT for isolated occlusions of the posterior cerebral artery.

METHODS

We retrospectively reviewed patients from three stroke centers with acute ischemic stroke attributed to isolated posterior cerebral artery occlusion (IPCAOs) who underwent MT between January 2014 and December 2019. Procedural and safety assessment included successful recanalization rates (defined as Thrombolysis in Cerebral Infarction Scale (TICI) ≥2b), number of MT attempts and first-pass effect (TICI 3), intracranial hemorrhage (ICH), mortality, and intervention-related serious adverse events. Treatment effects were evaluated by the rate of early neurological improvement (ENI) and early functional outcome was assessed with the modified Rankin Scale (mRS) at discharge. A systematic literature review was conducted to identify and summarize previous reports on MT for IPCAOs.

RESULTS

Forty-three patients with IPCAOs located in the P1 (55.8%, 24/43), P2 (37.2%, 16/43), and P3 segment (7%, 3/43) were analyzed. The overall rate of successful recanalization (TICI ≥2b) was 86% (37/43), including a first pass-effect of 48.8% (21/43) leading to TICI 3. sICH occurred in 7% (3/43) and there were two cases with iatrogenic vessel dissection and one perforation. ENI was observed in 59% (23/39) and excellent functional outcome (mRS ≤1) in 46.2% (18/39) of patients who were discharged. The in-hospital mortality rate was 9.3% (4/43).

CONCLUSION

Our study suggests the technical feasibility and safety of thrombectomy for IPCAOs. Further studies are needed to investigate safety and long-term functional outcomes with posterior circulation stroke-adjusted outcome assessment.

Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion

Background and Purpose—

We investigated efficacy and safety of acute revascularization with intravenous thrombolysis (IVT) and endovascular treatment (EVT) in ischemic stroke from isolated posterior cerebral artery occlusion, by assessing recanalization, disability, visual, cognitive outcomes, and hemorrhagic complications.

Methods—

For this retrospective single-center cohort study, we selected all consecutive patients with stroke with isolated posterior cerebral artery occlusion from the Acute Stroke Registry and Analysis of Lausanne registry between January 2003 and July 2018, and compared (1) IVT with conservative treatment (CTr) and (2) EVT to best medical therapy (BMT, ie, CTr or IVT) in terms of 3-month disability and visual field defect, and cognitive domains impaired after stroke. Unadjusted analysis, multivariable logistic regression, and propensity score matched analyses were performed.

Results—

Among 106 patients with isolated posterior cerebral artery occlusion, 21 received EVT (13 bridging), 34 IVT alone, and 51 CTr. Median age was 76 years, 47% were female and median National Institutes of Health Stroke Scale score was 7. Complete 24-hour recanalization was more frequent with IVT than CTr (51% versus 9%; OR [95% CI]=10.62 [2.13–52.92]) and with EVT compared with BMT (68% versus 34%; OR [95% CI]=4.11 [1.35–12.53]). Higher proportions of good disability, visual and cognitive outcomes were observed in IVT versus CTr, adj ORs (95% CI)=1.65 (0.60−4.52), 2.01 (0.58−7.01), 2.94 (0.35−24.4), respectively, and in EVT versus BMT, adj ORs (95% CI)=1.44 (0.51−4.10), 4.28 (1.00−18.29), 4.37 (0.72−26.53), respectively. Hemorrhagic complications and mortality did not increase with IVT or EVT.

Conclusion

s—We show increased odds of recanalization following IVT and even higher after EVT. We observed a trend for a positive effect on disability, visual, and cognitive outcomes with IVT over CTr and with EVT over BMT.

Neuropsychiatric symptoms as the only acute manifestation of a stroke in the left hemisphere. Case report

We report the case of a 60-year-old female patient with a history of hypertension and dyslipidemia, who suddenly presented with a clinical picture of emotional lability, disorientation, complex visual hallucinations and persecutory delusions. There were no associated neurological findings in her initial physical examination. At a local hospital she was initially diagnosed with late-onset bipolar disorder and a manic episode with psychotic features, then referred to the mental health unit, where nuclear magnetic resonance (NMR) imaging of the brain revealed an acute ischemic stroke in the territory of the left posterior cerebral artery (PCA) with haemorrhagic reperfusion to the occipital cortex. Complete and spontaneous resolution of her clinical condition was achieved after approximately 15 days.

Epidemiology, Clinical Presentation, and Prognosis of Posterior Circulation Ischemic Stroke in Children

BACKGROUND

Anterior and posterior circulation strokes are often different in terms of presentation and recurrence risk, but there are few studies that focused on posterior circulation stroke.

METHODS

We performed a longitudinal retrospective study of children, birth to 18 years, with posterior circulation ischemic stroke at the Children's Hospital Winnipeg from January 1992 to December 2012. Clinical and radiological features and outcomes were collected using standardized tools.

RESULTS

Of the 158 children with arterial ischemic stroke, 23 (14.5%) children, 21 non-neonates, and 11 males were identified. For posterior circulation ischemic stroke, mean crude incidence of 0.38 and crude mortality rate of 0.11 per 100,000 person-years was estimated. The crude total period prevalence rate for the study period was estimated as 8.1 per 100,000 children. Nonspecific symptoms before stroke presentation were present in 38% and impaired consciousness in 71%. Identifiable risk factors were present in two thirds: vasculopathy 24%, infection 19%, trauma 14%, and congenital heart disease 9.5%. Average Pediatric National Institutes of Health Stroke Scale score at presentation was 11. Poor outcome was noted in 45%. Outcome did not change significantly between 12 and 24 months. Aboriginal ethnicity (P = 0.01), high Pediatric National Institutes of Health Stroke Scale score (P = 0.001), bilateral infarction (P = 0.001), and large caliber artery territory infarction (P = 0.02) predicted poor outcome.

CONCLUSIONS

Our hospital-based incidence and outcome data provide valuable information to help direct treatment strategies and prognosticate children with posterior circulation ischemic stroke. Our study calls for close observation and early management of children with posterior circulation stroke, in particular with aboriginal ancestry and bilateral and large artery territory infarction.

Beyond textbook neuroanatomy: The syndrome of malignant PCA infarction

Given its limited vascular territory, occlusion of the posterior cerebral artery (PCA) usually does not result in malignant infarction. Challenging this concept, we present 3 cases of unilateral PCA infarction with secondary malignant progression, resulting from extension into what would classically be considered the posterior middle cerebral artery (MCA) territory. Interestingly, these were true PCA infarctions, not "MCA plus" strokes, since the underlying occlusive lesion was in the PCA. We hypothesize that congenital and/or acquired variability in the distribution and extent of territory supplied by the PCA may underlie this rare clinical entity. Patients with a PCA infarction should thus be followed closely and offered early surgical decompression in the event of malignant progression.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere.

METHODS

The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review.

RESULTS

Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients.

CONCLUSIONS

Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.

MRI multiparametric hemodynamic characterization of the normal brain

Characterization of the brain's vascular system is of major clinical importance in the assessment of patients with cerebrovascular disease. The aim of this study was to characterize brain hemodynamics using multiparametric methods and to obtain reference values from the healthy brain. A multimodal magnetic resonance imaging (MRI) study was performed in twenty healthy subjects, including dynamic susceptibility contrast imaging and blood oxygen level dependence (BOLD) during hypercapnia and carbogen challenges. Brain tissues were defined using unsupervised cluster analysis based on these three methods, and several hemodynamic parameters were calculated for gray matter (GM), white matter (WM), blood vessels and dura (BVD); the three main vascular territories within the GM; and arteries and veins defined within the BVD cluster. The carbogen challenge produced a BOLD signal twice as high as the hypercapnia challenge, in all brain tissues. The three brain tissues differed significantly from each other in their hemodynamic characteristics, supporting the graded vascularity of the tissues, with BVD>GM>WM. Within the GM cluster, a significant delay of ∼1.2 s of the bolus arrival time was detected within the posterior cerebral artery territory relative to the middle and anterior cerebral artery territories. No differences were detected between right and left middle cerebral artery territories for all hemodynamic parameters. Within the BVD cluster, a significant delay of ∼1.9 s of the bolus arrival time was detected within the veins relative to the arteries. This parameter enabled to differentiate between the various blood vessels, including arteries, veins and choroid plexus. This study provides reference values for several hemodynamic parameters, obtained from healthy brains, and may be clinically important in the assessment of patients with various vascular pathologies.

The relatively good outcome of cerebellum-brainstem ischemic strokes

BACKGROUND

Our clinical experience suggests that the outcome of cerebellum-brainstem ischemic strokes is better than that of hemispheric ischemic strokes.

METHODS

Within the setting of 2 national Israeli prospective stroke surveys, we analyzed risk factors, etiology, severity at presentation, and prognosis of first ischemic cerebellum-brainstem stroke (259 patients), comparing with strokes within the anterior circulation (1,029 patients).

RESULTS

Patients with cerebellum-brainstem strokes were younger and had less frequently atrial fibrillation and congestive heart failure. Cardioembolic etiology was significantly less prevalent (p < 0.001). Severity at presentation was milder (p < 0.001). At discharge, worsening of the modified Rankin Scale was present in a smaller number of patients (p < 0.001); more returned to their home (p < 0.001). Six-month and 1-year mortality were lower (p < 0.001 for both). Adjusted logistic regression models showed that patients with cerebellum-brainstem strokes had 50% smaller chances of dying (OR 0.55; 95% CI 0.31-0.98) and a smaller chance of worsening of the modified Rankin Scale at discharge (OR 0.61; 95% CI 0.46-0.82).

CONCLUSIONS

Cerebellum-brainstem strokes are less frequently cardioembolic, have a less severe presentation, and carry a better immediate and long-term prognosis.

Infarctions in the vascular territory of the posterior cerebral artery: clinical features in 232 patients

Background

Ischemic stroke caused by infarction in the territory of the posterior cerebral artery (PCA) has not been studied as extensively as infarctions in other vascular territories. This single centre, retrospective clinical study was conducted a) to describe salient characteristics of stroke patients with PCA infarction, b) to compare data of these patients with those with ischaemic stroke due to middle cerebral artery (MCA) and anterior cerebral artery (ACA) infarctions, and c) to identify predictors of PCA stroke.

Findings

A total of 232 patients with PCA stroke were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986-2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 232 patients with PCA stroke were compared with those of the 1355 patients with MCA infarctions and 51 patients with ACA infarctions included in the registry.

Infarctions of the PCA accounted for 6.8% of all cases of stroke (n = 3808) and 9.6% of cerebral infarctions (n = 2704). Lacunar infarction was the most frequent stroke subtype (34.5%) followed by atherothrombotic infarction (29.3%) and cardioembolic infarction (21.6%). In-hospital mortality was 3.9% (n = 9). Forty-five patients (19.4%) were symptom-free at hospital discharge. Hemianopia (odds ratio [OR] = 6.43), lacunar stroke subtype (OR = 2.18), symptom-free at discharge (OR = 1.92), limb weakness (OR = 0.10), speech disorders (OR = 0.33) and cardioembolism (OR = 0.65) were independent variables of PCA stroke in comparison with MCA infarction, whereas sensory deficit (OR = 2.36), limb weakness (OR = 0.11) and cardioembolism as stroke mechanism (OR = 0.43) were independent variables associated with PCA stroke in comparison with ACA infarction.

Conclusions

Lacunar stroke is the main subtype of infarction occurring in the PCA territory. Several clinical features are more frequent in stroke patients with PCA infarction than in patients with ischaemic stroke due to infarction in the MCA and ACA territories. In-hospital mortality in patients with PCA territory is low.