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Edlow JA, Bellolio F. Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness. Ann Emerg Med 2024:S0196-0644(24)00214-2. [PMID: 38795083 DOI: 10.1016/j.annemergmed.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/27/2024]
Abstract
Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.
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Affiliation(s)
- Jonathan A Edlow
- Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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Koyanagi M, Hatano T, Nakai M, Ogura T, Minematsu K, Kobayashi S, Toyoda K. Favorable prognosis in posterior circulation ischemic stroke: Insights from a nationwide stroke databank. J Neurol Sci 2024; 460:123000. [PMID: 38640583 DOI: 10.1016/j.jns.2024.123000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/20/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Clinical trials have historically underrepresented patients with posterior circulation ischemic stroke (PCIS). This study aimed to comprehensively assess the clinical characteristics and outcomes of PCIS patients compared to those with anterior circulation ischemic stroke (ACIS). METHODS A retrospective analysis was conducted using data from the Japan Stroke Data Bank, encompassing 20 years across 130 stroke centers. The study focused on patients diagnosed with PCIS or ACIS. RESULTS Among 37,069 patients reviewed, 7425 had PCIS, whereas 29,644 had ACIS. PCIS patients were younger and had a lower female representation than ACIS patients. Notably, PCIS patients had more favorable outcomes: 71% achieved a modified Rankin Scale of 0-2 or showed no deterioration at discharge (17 days at the median after admission), compared to 60% for ACIS patients (p < 0.001). Factors associated with an unfavorable outcome in the PCIS subgroup were older age, female sex (assigned at birth), history of hypertension, and higher National Institute of Health Stroke Scale (NIHSS) scores at admission. In both sexes, older age and higher NIHSS scores were negatively associated with favorable outcomes. CONCLUSIONS PCIS patients demonstrated a more favorable prognosis than ACIS patients. Factors like older age, female sex, and higher NIHSS scores at admission were identified as independent predictors of unfavorable outcomes in PCIS patients. Older age and higher NIHSS scores at admission were common independent negative factors for a favorable outcome regardless of sex.
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Affiliation(s)
- Masaomi Koyanagi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan.
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan; Clinical Research Support Center, University of Miyazaki Hospital, Miyazaki, Japan
| | - Takenori Ogura
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | | | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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David AM, Jaleel A, Joy Mathew CM. Misdiagnosis of Cerebellar Infarcts and Its Outcome. Cureus 2023; 15:e35362. [PMID: 36974239 PMCID: PMC10039737 DOI: 10.7759/cureus.35362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 02/25/2023] Open
Abstract
Cerebellar infarction, a rare category of stroke, is often misdiagnosed but not given much importance in the available literature. Its presentation overlaps with symptoms of other neurologic, cardiovascular, gastrointestinal, and systemic conditions and therefore is nonspecific. Early diagnosis and management of cerebellar strokes are of utmost importance as the lack of a proper diagnosis may increase overall morbidity and mortality. Lack of awareness of the warning signs and symptoms, non-specificity of symptoms, absence of neurological deficits, and imaging discrepancies are some of the factors contributing to misdiagnosis and delayed treatment. If symptomatology is considered, it is found that symptoms of posterior circulation stroke were more frequently misdiagnosed compared to anterior circulation. Nausea and vomiting increased the chance further. Some other rare presentations include gastrointestinal symptoms, isolated vertigo, and symptoms of inner ear disease. Overdependence on radiological investigations often masks the significance of clinical examination. Ischemic stroke may appear normal in the initial 48 hours in the computed tomography scan of the brain or bony artefacts may hide the lesion. Permanent disabling deficits can follow a cerebellar stroke and the complications, which include hydrocephalus, brain stem compression, and gait abnormalities, necessitate prompt identification and management. In this review article, we aim at analysing various case reports of cerebellar infarction, the most common presentations that were under-evaluated, and their outcomes, thereby highlighting the importance of proper diagnosis and reporting of cerebellar infarction in the future. A thorough knowledge of the association between various clinical presentations of cerebellar stroke and its misdiagnosis helps clinicians to be more vigilant about the disease.
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Wiseman K, Gor D, Upadrasta G, Udongwo N, Lanpher K, Douedi S, Patel SV. A Cerebrovascular Accident Presenting With Bilateral Vocal Cord Paresis. Cureus 2021; 13:e17840. [PMID: 34660047 PMCID: PMC8501465 DOI: 10.7759/cureus.17840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 11/05/2022] Open
Abstract
Diagnosing a stroke requires careful attention to clinical indicators on physical exam, especially the more subtle manifestations of cerebellar lesions. An 85-year-old male with vascular risk factors and new-onset atrial fibrillation was admitted for left upper extremity weakness, headaches, and tremors. The patient developed stridor during hospitalization and was found to have a new cerebellar infarct with hemorrhagic transformation on computed tomography (CT) of the head, with laryngoscopy showing bilateral vocal cord paresis. While strokes outside of the cerebellum are a known cause of unilateral vocal cord paresis, cerebellar strokes are a rare culprit and rarely cause bilateral cord paresis. Consideration beyond the more common pulmonary and iatrogenic causes of vocal cord paresis should be considered, with particular attention to stroke.
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Affiliation(s)
- Kyle Wiseman
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Dhairya Gor
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Gautham Upadrasta
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Ndausung Udongwo
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Kara Lanpher
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Steven Douedi
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Swapnil V Patel
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
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Shang YX, Yan LF, Cornett EM, Kaye AD, Cui GB, Nan HY. Incidence of Cerebral Infarction in Northwest China From 2009 to 2018. Cureus 2021; 13:e17576. [PMID: 34646631 PMCID: PMC8480718 DOI: 10.7759/cureus.17576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a lack of epidemiological analysis of patients with cerebral infarction in northwest China. In the present investigation, we conducted a retrospective analysis to collect information on epidemiological characteristics of patients with cerebral infarction in five provinces of northwest China and the Shanxi Province of patients who were hospitalized in the Tangdu Hospital. This project should provide a scientific basis for active prevention and treatment of cerebral infarction. MATERIAL AND METHODS A retrospective analysis of patients with epidemic characteristics of cerebral infarction that were admitted to the Tangdu Hospital of northwest China from January 2009 to December 2018. RESULTS A total of 18,302 patients (aged 1-97 years) with confirmed cerebral infarction, including 12,201 males and 6,101 females, were retrospectively enrolled in this study. The most common lesion site was the cerebellum (51.5%). The incidence of cerebral infarction was slightly higher in workers and laborers, favoring male patients and those aged 40-70 years. The difference between men and women gradually increased after the age of 30. CONCLUSIONS In this study, 18,302 hospitalized patients with cerebral infarction from different occupations were included. Those engaged in physical labor were more likely to have a cerebral infarction. The incidence of cerebral infarction in males was higher than in females. Cerebellar and cerebral area infarctions were the most common.
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Affiliation(s)
- Yu-Xuan Shang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Fourth Military Medical University, Shaanxi, CHN
| | - Lin-Feng Yan
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Fourth Military Medical University, Shaanxi, CHN
| | - Elyse M Cornett
- Department of Anaesthesiology, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Alan D Kaye
- Department of Anaesthesiology, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Guang-Bin Cui
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Fourth Military Medical University, Shaanxi, CHN
| | - Hai-Yan Nan
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Fourth Military Medical University, Shaanxi, CHN
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Impact of revascularization therapies on outcome of posterior circulation ischemic stroke: The Indo-US stroke project. J Neurol Sci 2021; 427:117499. [PMID: 34029753 DOI: 10.1016/j.jns.2021.117499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/23/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry. METHODS Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS). RESULTS Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p < 0.001). Diabetes mellitus and hypertension were more common in PCS and rheumatic heart disease in ACS. Small artery occlusion was higher in PCS (23.8% vs 12.9%, p < 0.001). Only 28 (6.8%) PCS received RT compared to 213 (14.4%) ACS. At 90 days, a good functional outcome (mRS 0-2) was more common in PCS (56.4% vs 45.9%, p < 0.001) in NRT group, while no significant difference was noted in RT group. Stroke territory was not an independent predictor of 3-month outcome in regression analysis. In-hospital mortality was not different between the groups. CONCLUSIONS The 3-month functional outcome and in-hospital mortality were not different between ACS and PCS. Compared to ACS, PCS received revascularization therapies less often.
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Wang ML, Yu MM, Li WB, Li YH. Application of neutrophil to lymphocyte ratio to identify CT-negative cerebral infarction with nonfocal symptoms. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1359. [PMID: 33313104 PMCID: PMC7723643 DOI: 10.21037/atm-20-1640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The neutrophil to lymphocyte ratio (NLR) has emerged as a strong predictor of mortality in stroke patients. Our study aimed to investigate the correlation between NLR and cerebral infarction with nonfocal symptoms confirmed by diffusion-weighted imaging (DWI) (+). Methods A total of 439 patients with nonfocal stroke symptoms with CT-negative findings were included from January 1 to December 31, 2018. All patients underwent a head MRI examination within seven days following a head CT examination. The patients’ demographics, medical history, presenting symptoms, and stroke location were recorded. Logistic regression and receiver operating characteristic (ROC) curve analysis were used to identify variables with a significant association with cerebral infarction. Results Cerebral infarction was detected in 79 (18%) patients confirmed by DWI(+), located mostly in the cerebellum (40.51%). Dizziness (85.19%) was the most common symptom. The cerebral infarction group showed a higher prevalence of hypertension (P<0.0001), diabetes mellitus (P<0.0001), and smoking status (P=0.001) than non-cerebral infarction group. The NLR (P<0.0001) was higher in the cerebral infarction group. There was no significant difference in NIHSS (P=0.09). Logistic analysis revealed that male gender (P=0.046), a history of hypertension (P=0.001), diabetes mellitus (P=0.001), smoking (P=0.023), and NLR (P<0.0001) were the best predictors of cerebral infarction. When integrating sex, hypertension, diabetes mellitus, smoking and NLR, the area under ROC value of the combined method was 0.785, higher than any separate parameters (P<0.05). Conclusions NLR combined with male gender, a history of hypertension, diabetes mellitus, and smoking, could predict DWI-confirmed cerebral infarction with nonfocal neurologic symptoms with high diagnostic accuracy.
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Affiliation(s)
- Ming-Liang Wang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng-Meng Yu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Bin Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue-Hua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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One-year prognosis of transient ischemic attacks with nonfocal symptoms. Clin Neurol Neurosurg 2020; 196:105977. [PMID: 32512406 DOI: 10.1016/j.clineuro.2020.105977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A few studies suggested an increased risk of stroke or coronary heart disease in patients with transient ischemic attacks (TIA) presenting with nonfocal symptoms. We aimed to assess the vascular prognosis of TIA patients with and without accompanying nonfocal symptoms. PATIENTS AND METHODS Observational study of consecutive patients with TIA referred to a TIA Clinic from March 2004 to March 2011. Primary outcome was the composite of any event: stroke, TIA, myocardial infarction (MI) or vascular death in the first year of follow-up; secondary outcomes included individual components of the primary outcome. Hazard ratios were calculated with Cox regression. RESULTS 429 TIA patients were enrolled, 329 (76.7 %) with only focal symptoms, and 100 (23.3 %) with both focal and nonfocal symptoms. In the first year after TIA, the primary outcome occurred in 65 patients (16.0 %; 95 % CI, 12 %-19 %): stroke, in 28 patients; TIA, in 31 patients; MI and vascular death in two patients each. The frequency of the composite outcome was similar in patients with or without nonfocal symptoms (16 events (17.0 %; 95 % CI, 10-24) vs. 49 events (15.7 %; 95 % CI, 12-20 %); p = 0.430). There were no significantly differences in the frequency of any of the secondary outcomes between patients with or without nonfocal symptoms. CONCLUSION Almost one-fourth of TIA patients reported concomitant nonfocal symptoms, but they had the same risk of stroke and cardiovascular events as patients with isolated focal symptoms.
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Gurley KL, Edlow JA. Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review. Acad Emerg Med 2019; 26:1273-1284. [PMID: 31295763 DOI: 10.1111/acem.13830] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/29/2019] [Accepted: 06/08/2019] [Indexed: 12/22/2022]
Abstract
Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.
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Affiliation(s)
- Kiersten L. Gurley
- Harvard Medical School Beth Israel Deaconess Medical Center Boston MA
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
- Mount Auburn Hospital Cambridge MA
| | - Jonathan A. Edlow
- Harvard Medical School Beth Israel Deaconess Medical Center Boston MA
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MA
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10
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Posterior circulation ischaemic stroke-a review part I: anatomy, aetiology and clinical presentations. Neurol Sci 2019; 40:1995-2006. [PMID: 31222544 DOI: 10.1007/s10072-019-03977-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
Posterior circulation ischaemia is a clinicopathological condition with complex symptomatology associated with an infarction within the vertebrobasilar arterial system. Posterior circulation strokes account for about 20-25% of all ischemic strokes and remain a significant cause of patient disability and mortality. Diagnosis can be challenging because presenting symptoms are often non-focal and because there is a substantial overlap in symptoms and signs of ischaemia in the anterior circulation. Despite better imaging techniques, diagnosis and treatment of life-threatening conditions, such as basilar artery occlusions, are often delayed. Therefore, early detection of symptoms and causes of posterior circulation ischaemia is essential for choosing the most appropriate therapy. In this review, we summarise the anatomy, aetiology, typical presentations and characteristic findings of common strokes resulting from disease in the vertebrobasilar arterial system.
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Oudeman EA, Volkers EJ, Greving JP, Klijn CJM, Algra A, Kappelle L. Nonfocal transient neurological attacks in patients with carotid artery occlusion. Eur Stroke J 2019; 4:50-54. [PMID: 31165094 PMCID: PMC6533861 DOI: 10.1177/2396987318818779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/10/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Nonfocal transient neurological attacks (TNAs) are episodes with atypical,
nonlocalizing cerebral symptoms. We examined the prevalence of nonfocal
TNAs, in patients with and without carotid artery occlusion (CAO). Methods We included 67 patients with CAO and 62 patients without CAO. In both groups,
patients had a history of transient ischemic attack (TIA) or nondisabling
ischemic stroke in the anterior circulation that had occurred >6 months
before inclusion. Patients without CAO did not have ipsilateral or
contralateral carotid artery stenosis of ≥50%. All patients were interviewed
with a standardized questionnaire on the occurrence of nonfocal TNA symptoms
during the preceding six months. We calculated risk ratios (RRs) with 95%
confidence intervals (CIs) for the occurrence of ≥1 and ≥2 different
nonfocal TNAs after adjustments for age, sex, systolic blood pressure and
time interval between most recent TIA or ischemic stroke and administration
of the questionnaire. Results Forty-three of all patients (33%) had had one or more nonfocal TNAs in the
preceding six months. Nonrotatory dizziness (24%) was reported most often.
The prevalence of ≥1 nonfocal TNAs was not significantly different between
patients with and without CAO (39% vs. 27%; adjusted RR 1.47, 95% CI
0.83–2.61), but the prevalence of ≥2 or more different nonfocal TNAs was
higher in patients with CAO (16% vs. 3%; adjusted RR 4.77, 95% CI
1.20–18.98). In patients with CAO who also had a contralateral carotid or
vertebral artery steno-occlusion, nonfocal TNAs occurred more often than in
patients without any carotid or vertebral artery steno-occlusion (46% vs.
27%; adjusted RR 2.22, 95% CI 1.08–4.60 for ≥1 and 21% vs. 3%; adjusted RR
8.27, 95% CI 1.83–37.32 for ≥2 nonfocal TNAs). Conclusions Patients with CAO more often experienced multiple nonfocal TNAs than patients
without CAO.
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Affiliation(s)
- Eline A Oudeman
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Department of Neurology, OLVG west, Amsterdam, the
Netherlands
- Eline A Oudeman, Department of Neurology,
University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508, GA, The
Netherlands.
| | - Eline J Volkers
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P Greving
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Catharina JM Klijn
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Department of Neurology, Donders Institute for Brain, Cognition,
and Behavior, Center for Neuroscience, Radboud University Medical Center,
Nijmegen, the Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
- Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L.Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Centre Rudolf
Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, the
Netherlands
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Khasanov IA, Bogdanov EI. Significance of focal and nonfocal symptoms in the diagnostics of transient vertebrobasilar ischemic syndromes. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:15-21. [DOI: 10.17116/jnevro201911905115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Chi HY, Hsu CF, Chen AC, Su CH, Hu HH, Fu WM. Extracranial and Intracranial Ultrasonographic Findings in Posterior Circulation Infarction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1605-1610. [PMID: 29193196 DOI: 10.1002/jum.14501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Patients with posterior circulation infarction are at higher risk of early recurrent stroke, especially those with vertebrobasilar stenosis or hypoplasia. The clinical presentations of this condition vary over a broad range, making diagnosis and treatment a challenge. Hemodynamic changes and stenosis detected by ultrasonography (US) are sensitive and important indicators for further evaluation. In this study, we correlated extracranial and intracranial US characteristics with brain magnetic resonance imaging (MRI) in patients with posterior circulation infarction. METHODS Inpatients with acute ischemic stroke who received both MRI and US were enrolled. Baseline characters, underlying disorders, the ischemic territory, and vascular stenosis on MRI were recorded. Series of US data, including flow volume, diameter, mean velocity, and pulsatility index, were analyzed. Patients with new infarction over the medulla, pons, midbrain, or cerebellum were enrolled as the posterior circulation infarction group. Patients with pure anterior circulation infarction were also enrolled. RESULTS A total of 210 patients with anterior circulation infarction (mean age ± SD, 66.24 ± 12.88 years) and 143 with posterior circulation infarction (mean age, 65.82 ± 11.39 years) were enrolled. Significant higher frequencies of vertebral artery hypoplasia and decreased intracranial vertebrobasilar velocity in the posterior circulation infarction group (44.75% and 64.33%, respectively) were documented (P < .0001; P = .035). Ischemic lesion distributions were correlated with vertebral artery hypoplasia (55.56 %) and low vertebral and basilar artery velocities (44.44% and 25.53%), as documented by US. A low vertebrobasilar velocity was highly correlated with MRI-documented vascular stenosis (53.06%). CONCLUSIONS Vertebral artery hypoplasia and a low velocity in the intracranial vertebrobasilar system on US might change the treatment of patients with posterior circulation infarction for primary and secondary prevention.
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Affiliation(s)
- Hsin-Yi Chi
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Pharmacological Institute, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chung-Fu Hsu
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - An-Chih Chen
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chun-Hung Su
- Department of Internal Medicine, Division of Cardiology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Han-Hwa Hu
- Graduate Institute of Clinical Medicine and Department of Neurology, College of Medicine, Taipei Medical University and Hospital, Taipei, Taiwan
| | - Wen-Mei Fu
- Pharmacological Institute, College of Medicine, National Taiwan University, Taipei, Taiwan
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Ausman JI, Liebeskind DS, Gonzalez N, Saver J, Martin N, Villablanca JP, Vespa P, Duckwiler G, Jahan R, Niu T, Salamon N, Yoo B, Tateshima S, Buitrago Blanco MM, Starkman S. A review of the diagnosis and management of vertebral basilar (posterior) circulation disease. Surg Neurol Int 2018; 9:106. [PMID: 29930872 PMCID: PMC5991286 DOI: 10.4103/sni.sni_373_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/26/2017] [Indexed: 12/28/2022] Open
Abstract
We have reviewed the English literature published in the last 70 years on Diseases of the Vertebral Basilar Circulation, or Posterior Circulation Disease (PCD). We have found that errors have been made in the conduct and interpretation of these studies that have led to incorrect approaches to the management of PCD. Because of the difficulty in evaluating the PC, the management of PCD has been incorrectly applied from anterior circulation disease (ACD) experience to PCD. PCD is a common form of stroke affecting 20-40% patients with stroke. Yet, the evidence is strong that the Anterior Circulation (AC) and Posterior Circulations (PC) differ in their pathology, in their clinical presentations, in the rapidity of development of symptoms, in optimal imaging methods, and in available treatments. There appears to be two categories of patients who present with PCD. The first, acute basilar artery occlusion has a more rapid onset. The diagnosis must be made quickly and if imaging proves a diagnosis of Basilar Artery Occlusion (BAO), the treatment of choice is Interventional removal of the basilar artery thrombosis or embolus. The second category of PCD and the most commonly seen PCD disease process presents with non-specific symptoms and early warnings of PCD that now can be related to ischemic events in the entire PC vessels. These warning symptoms and signs occur much earlier than those in the AC. IA angiography is still the gold standard of diagnosis and is superior in definition to MR and CT angiography which are commonly used as a convenient screening imaging tool to evaluate PCD but are both inferior to IA angiography in definition for lesions below 3-4 mm. In at least two reported studies 7T MR angiography appears superior to other imaging modalities and will become the gold standard of imaging of PCD in the future. Medical treatments applied to the ACD have not been proven of value in specific forms of PCD. Interventional therapy was promising but of unproven value in Randomized Controlled Trials (RCT) except for the treatment of Basilar Artery Occlusion (BAO). Surgical revascularization has been proved to be highly successful in patients, who are refractory to medical therapy. These studies have been ignored by the scientific community basically because of an incorrect interpretation of the flawed EC-IC Bypass Trial in 1985 as applying to all stroke patients. Moreover, the EC-IC Bypass Study did not include PCD patients in their study population, but the study results were extrapolated to patients with PCD without any scientific basis. This experience led clinicians to an incorrect bias that surgical treatments are of no value in PCD. Thus, incorrectly, surgical treatments of PCD have not been considered among the therapeutic possibilities for PCD. QMRA is a new quantitative MR technique that measures specific blood flow in extra and intracranial vessels. QMRA has been used to select those patients who may benefit from medical, or interventional, or surgical treatment for PCD based on flow determinations with a high success rate. QMRA accurately predicts the flows in many large and small vessels in the PC and AC and clearly indicates that both circulations are intimately related. From medical and surgical studies, the longer one waits for surgical treatment the higher the risk of a poor outcome results. This observation becomes obvious when the rapidity of development of PCD is compared with ACD. Recent advances in endovascular therapy in the treatment of acute basilar thrombosis is a clear sign that early diagnosis and treatment of PCD will reduce the morbidity and mortality of these diseases. In this review it is evident that there are multiple medical and surgical treatments for PCD depending upon the location of the lesion(s) and the collateral circulation demonstrated. It is clear that the AC and PC have significant differences. With the exception of the large population studies from Oxford England, the reported studies on the management of PCD in the literature represent small selected subsets of the universe of PC diseases, the information from which is not generalizable to the universe of PCD patients. At this point in the history of PCD, there are not large enough databases of similar patients to provide a basis for valid randomized studies, with the exception of the surgical studies. Thus, a high index of suspicion of the early warning symptoms of PCD should lead to a rapid individual clinical assessment of patients selecting those with PCD. Medical, interventional, and/or surgical treatments should be chosen based on knowledge presented in this review. Recording the results in a national Registry on a continuing basis will provide the data that may help advance the management of PCD based on larger data bases of well documented patient information to guide the selection of future therapies for PCD treatments. It is also clear that the management of patients within the complex of diseases that comprise PCD should be performed in centers with expertise in the imaging, medical, interventional and surgical approaches to diseases of the PCD.
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Affiliation(s)
- James I. Ausman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David S. Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Neurovascular Imaging Research Core, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nestor Gonzalez
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jeffrey Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil Martin
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - J. Pablo Villablanca
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Paul Vespa
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Tianyi Niu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Bryan Yoo
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Manuel M. Buitrago Blanco
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Sidney Starkman
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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16
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De Cocker LJL, Lövblad KO, Hendrikse J. MRI of Cerebellar Infarction. Eur Neurol 2017; 77:137-146. [PMID: 28095387 DOI: 10.1159/000455229] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND MRI is the imaging modality of choice for diagnosing brain infarction. Because of few or atypical clinical symptoms and a relatively low sensitivity of CT scans, many cerebellar infarctions may be detected only with MRI. With adequate recognition of cerebellar infarction on MRI and prompt initiation or optimisation of preventive therapeutic measures, more dramatic strokes may be avoided in selected cases. SUMMARY We first briefly review the clinical presentation of cerebellar infarctions, followed by a short refresher on cerebellar anatomy and pathophysiological mechanisms of cerebellar infarcts. Then, we review the arterial cerebellar perfusion territories recently made visible with territorial arterial spin labeling (ASL), followed by a discussion and illustration of the MRI appearance of cerebellar infarcts in different stages. Similar to large cerebellar infarcts, recent studies investigating volumetric MRI datasets have now shown that small cerebellar infarcts occur in typical spatial patterns, knowledge of which may help in the diagnosis of even the smallest of cerebellar infarcts on MRI. Key Messages: MRI is the modality of choice for diagnosing cerebellar infarction. The posterior inferior cerebellar artery (PICA)-territories can be visualised with super-selective territorial ASL MRI. The PICA supplies at least the medial part of the posterior cerebellar surface. Anterior inferior cerebellar artery-infarcts can be mistaken for lateral PICA-infarcts. Small infarcts typically affect the cortex and often present as incidental cavities. Subacute cerebellar infarcts may be missed on imaging due to a phenomenon called "fogging."
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Affiliation(s)
- Laurens J L De Cocker
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Cerebellar cortical infarct cavities and vertebral artery disease. Neuroradiology 2016; 58:853-7. [PMID: 27236563 DOI: 10.1007/s00234-016-1707-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Cerebellar cortical infarct cavities are a newly recognised entity associated with atherothromboembolic cerebrovascular disease and worse physical functioning. We aimed to investigate the relationship of cerebellar cortical infarct cavities with symptomatic vertebrobasilar ischaemia and with vascular risk factors. METHODS We evaluated the MR images of 46 patients with a recent vertebrobasilar TIA or stroke and a symptomatic vertebral artery stenosis ≥50 % from the Vertebral Artery Stenting Trial (VAST) for the presence of cerebellar cortical infarct cavities ≤1.5 cm. At inclusion in VAST, data were obtained on age, sex, history of vertebrobasilar TIA or stroke, and vascular risk factors. Adjusted risk ratios were calculated with Poisson regression analyses for the relation between cerebellar cortical infarct cavities and vascular risk factors. RESULTS Sixteen out of 46 (35 %) patients showed cerebellar cortical infarct cavities on the initial MRI, and only one of these 16 patients was known with a previous vertebrobasilar TIA or stroke. In patients with symptomatic vertebrobasilar ischaemia, risk factor profiles of patients with cerebellar cortical infarct cavities were not different from patients without these cavities. CONCLUSION Cerebellar cortical infarct cavities are seen on MRI in as much as one third of patients with recently symptomatic vertebral artery stenosis. Since patients usually have no prior history of vertebrobasilar TIA or stroke, cerebellar cortical infarct cavities should be added to the spectrum of common incidental brain infarcts visible on routine MRI.
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18
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Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 2016; 33:577-99, viii. [PMID: 26231273 DOI: 10.1016/j.ncl.2015.04.011] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.
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Affiliation(s)
- David E Newman-Toker
- Johns Hopkins Hospital, CRB-II, Room 2M-03 North, 1550 Orleans Street, Baltimore, MD 21231, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine Administrative Offices, Beth Israel Deaconess Medical Center, West CC-2, 1 Deaconess Place, Boston, MA 02215, USA
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19
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van Rooij FG, Vermeer SE, Góraj BM, Koudstaal PJ, Richard E, de Leeuw FE, van Dijk EJ. Diffusion-weighted imaging in transient neurological attacks. Ann Neurol 2015; 78:1005-10. [DOI: 10.1002/ana.24539] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/18/2015] [Accepted: 10/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Frank G. van Rooij
- Department of Neurology; Center for Neuroscience, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center; Nijmegen the Netherlands
| | - Sarah E. Vermeer
- Department of Neurology; Rijnstate Hospital; Arnhem the Netherlands
| | - Bozena M. Góraj
- Department of Radiology; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Diagnostic Imaging; Medical Center of Postgraduate Education; Warsaw Poland
| | - Peter J. Koudstaal
- Department of Neurology; Erasmus Medical Center; Rotterdam the Netherlands
| | - Edo Richard
- Department of Neurology; Center for Neuroscience, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center; Nijmegen the Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology; Center for Neuroscience, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center; Nijmegen the Netherlands
| | - Ewoud J. van Dijk
- Department of Neurology; Center for Neuroscience, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center; Nijmegen the Netherlands
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20
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Blum CA, Kasner SE. Transient Ischemic Attacks Presenting with Dizziness or Vertigo. Neurol Clin 2015; 33:629-42, ix. [DOI: 10.1016/j.ncl.2015.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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21
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De Cocker LJL, Geerlings MI, Hartkamp NS, Grool AM, Mali WP, Van der Graaf Y, Kloppenborg RP, Hendrikse J. Cerebellar infarct patterns: The SMART-Medea study. NEUROIMAGE-CLINICAL 2015; 8:314-21. [PMID: 26106556 PMCID: PMC4473120 DOI: 10.1016/j.nicl.2015.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 01/30/2015] [Accepted: 02/03/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Previous studies on cerebellar infarcts have been largely restricted to acute infarcts in patients with clinical symptoms, and cerebellar infarcts have been evaluated with the almost exclusive use of transversal MR images. We aimed to document the occurrence and 3D-imaging patterns of cerebellar infarcts presenting as an incidental finding on MRI. METHODS We analysed the 1.5 Tesla MRI, including 3D T1-weighted datasets, of 636 patients (mean age 62 ± 9 years, 81% male) from the SMART-Medea study. Cerebellar infarct analyses included an assessment of size, cavitation and gliosis, of grey and white matter involvement, and of infarct topography. RESULTS One or more cerebellar infarcts (mean 1.97; range 1-11) were detected in 70 out of 636 patients (11%), with a total amount of 138 infarcts identified, 135 of which showed evidence of cavitation. The average mean axial diameter was 7 mm (range 2-54 mm), and 131 infarcts (95%) were smaller than 20 mm. Hundred-thirty-four infarcts (97%) involved the cortex, of which 12 in combination with subcortical white matter. No infarcts were restricted to subcortical branches of white matter. Small cortical infarcts involved the apex of a deep (pattern 1) or shallow fissure (pattern 2), or occurred alongside one (pattern 3) or opposite sides (pattern 4) of a fissure. Most (87%) cerebellar infarcts were situated in the posterior lobe. CONCLUSIONS Small cerebellar infarcts proved to be much more common than larger infarcts, and preferentially involved the cortex. Small cortical infarcts predominantly involved the posterior lobes, showed sparing of subcortical white matter and occurred in characteristic topographic patterns.
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Affiliation(s)
- Laurens J L De Cocker
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nolan S Hartkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne M Grool
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem P Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolanda Van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raoul P Kloppenborg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands ; Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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22
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Compter A, van der Worp HB, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Is the long-term prognosis of transient ischemic attack or minor ischemic stroke affected by the occurrence of nonfocal symptoms? Stroke 2014; 45:1318-23. [PMID: 24652304 DOI: 10.1161/strokeaha.113.004360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In patients with a transient ischemic attack or ischemic stroke, nonfocal neurological symptoms, such as confusion and nonrotatory dizziness, may be associated with a higher risk of vascular events. We assessed the relationship between nonfocal symptoms and the long-term risk of vascular events or death in patients with a transient ischemic attack or minor ischemic stroke. METHODS We related initial symptoms with outcome events in 2409 patients with a transient ischemic attack (n=723) or minor ischemic stroke (n=1686), included in the Life Long After Cerebral ischemia cohort. All patients underwent a standardized interview on the occurrence of focal and nonfocal neurological symptoms during the qualifying event. The primary outcome was the composite of any stroke, myocardial infarction, or vascular death. Secondary outcomes were all-cause death, vascular death, cardiac death, myocardial infarction, and stroke. Hazard ratios were calculated with Cox regression. RESULTS Focal symptoms were accompanied by nonfocal symptoms in 739 (31%) patients. During a mean follow-up of 10.1 years, the primary outcome occurred in 1313 (55%) patients. There was no difference in the risk of the primary outcome between patients with both focal and nonfocal symptoms and patients with focal symptoms alone (adjusted hazard ratio, 0.97; 95% confidence interval, 0.86-1.09; P=0.60). The risk of each of the secondary outcomes was also similar in both groups. CONCLUSIONS About one third of the patients with a transient ischemic attack or minor ischemic stroke has both focal and nonfocal neurological symptoms. Nonfocal symptoms are not associated with an increased long-term risk of vascular events or death. CLINICAL TRIAL REGISTRATION This trial was not registered because enrollment began before July 1, 2005.
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Affiliation(s)
- Annette Compter
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands (A.C., H.B.v.d.W., J.v.G., L.J.K., A.A.); Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands (P.J.K.); and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (A.A.)
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23
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Markus HS, van der Worp HB, Rothwell PM. Posterior circulation ischaemic stroke and transient ischaemic attack: diagnosis, investigation, and secondary prevention. Lancet Neurol 2013; 12:989-98. [DOI: 10.1016/s1474-4422(13)70211-4] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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