Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review

INTRODUCTION

Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate.

MATERIAL & METHOD

We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman.

CONCLUSION

Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.

General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis

INTRODUCTION

The best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain.

METHOD

We searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications.

RESULTS

A total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45-1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94-2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44-1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40-1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91-1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70-1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61-2.32; P=0.616; I2=64.9%;) between the two groups.

CONCLUSIONS

Our study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.

Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes

Objective

This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI.

Methods

The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified.

Results

PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy.

Discussion

PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy.

Visual symptoms in acute stroke - A systematic review of observational studies

OBJECTIVE

Atypical symptoms of stroke, such as non-specific visual symptoms, are a challenging aspect of acute stroke diagnostics. Among patients evaluated for stroke in the Emergency Department, 2-28% present with stroke chameleons, and 30-43% with stroke mimics. We aimed to identify the type of visual symptoms present in typical strokes, stroke mimics, and stroke chameleons.

PATIENTS AND METHODS

By use of Preferred Reporting Items for Systematic Reviews and Meta-Analysis we searched PubMed and Embase for studies with reports of acute visual symptoms in typical strokes vs mimics or chameleons (PROSPERO protocol, ID CRD42022364749). Risk of bias was assessed by The Critical Appraisal Skills Program.

RESULTS

Thirteen papers were included, comprising data from 9248 patients evaluated for stroke. Compared to mimics, visual symptoms in stroke presented more frequently as hemianopia (28.2% vs 4.8%, 7,4% vs 2.3%, 22% vs 0%), visual loss (11.6% vs 1.8%), visual field defect (11.6% vs 4%, 24% vs 2%, 19% vs 1.7%), eye movement disorder (19.4% vs 6.4%), eye deviation (9.6% vs 0.9%), gaze palsy (32.1% vs 8.6%), oculomotor disturbance (37% vs 0%), and visual inattention (17.5% vs 4%). Compared to strokes, mimics more often presented "non-systematized visual trouble" (10% vs 3%) and blurred vision (22% vs 5%), whereas "visual disturbance" was reported more often in stroke chameleons than in typical strokes (10% vs 3%).

CONCLUSION

Detailed reports of visual symptoms were lacking in most studies, however blurred vision and "non-systematized visual trouble" were more frequent in mimics, "visual disturbance" in stroke chameleons, and negative visual symptoms such as visual field defects in typical strokes. A more systematic and detailed approach to visual symptoms may facilitate acute stroke recognition in patients with visual symptoms.

The Effect of Cerebellar Repetitive Transcranial Magnetic Stimulation on Dysphagia due to Posterior Circulation Stroke, a Randomized Controlled Trial Protocol

INTRODUCTION

Cerebellum might be active during the task of swallowing. Little is known whether cerebellar repetitive transcranial magnetic stimulation (rTMS) could improve post-stroke dysphagia (PSD) due to occlusion in the posterior circulation. This paper describes the rationale and design of a randomized controlled trial that aims to determine the effect of cerebellar rTMS on dysphagia due to posterior circulation stroke.

METHODS AND ANALYSIS

Thirty patients with PSD due to occlusion in the posterior circulation will be randomly divided to receive real (n = 20) or sham (n = 10) cerebellar rTMS. Patients in the real rTMS group will receive 250 pulses rTMS at a low intensity with 10 Hz frequency for 10 days (five consecutive days per week). The severity of dysphagia will be assessed with videofluoroscopic swallowing study (VFSS) using the Rosenbek penetration aspiration scale (PAS), the pharyngeal constriction ratio (PCR), and the dysphagia outcome and severity scale (DOSS) before and immediately after the last session and then again after 1 and 3 months. The functional magnetic resonance imaging (fMRI) will be assessed before and after the last session and then again after 1 month and 3 months. The primary outcome is the improvement of swallowing function determined by PAS, PCR, and DOSS. The secondary outcomes include changes in brain connectivity network detected using fMRI.

DISCUSSION

This study will determine whether cerebellar rTMS improves dysphagia due to posterior circulation stroke in Chinese patients. Our findings will contribute to a new approach for swallowing function recovery after posterior circulation stroke.

Imaging-based outcome prediction in posterior circulation stroke

BACKGROUND AND PURPOSE

We developed a machine learning model to allow early functional outcome prediction for patients presenting with posterior circulation (pc)-stroke based on CT-imaging and clinical data at admission. The proposed algorithm utilizes quantitative information from automated multidimensional assessments of posterior circulation Acute Stroke Prognosis Early CT-Score (pc-ASPECTS) regions. Discriminatory power was compared to predictions based on conventional pc-ASPECTS ratings.

METHODS

We retrospectively analyzed non-contrast CTs and clinical data of 172 pc-stroke patients. 90 days outcome was dichotomized into good and poor using modified Rankin Scale (mRS) cut-offs. Predictive performance was assessed for outcome differentiation at mRS 2, 3, 4 and survival prediction (mRS ≤ 5) using random forest algorithms. Results were compared to conventional pc-ASPECTS and clinical parameters. Models were evaluated in a nested fivefold cross-validation approach.

RESULTS

Receiver operating characteristic areas under the curves (ROC-AUCs) of the test sets using conventionally rated pc-ASPECTS reached 0.63 for mRS ≤ 4 to 0.68 for mRS ≤ 5 and 0.73 for mRS ≤ 5 to 0.85 for mRS ≤ 2 if clinical data were considered. Pure imaging-based machine learning classifier ROC-AUCs were lowest for mRS ≤ 4 (0.81) and highest for mRS ≤ 5 (0.87). The combined clinical data and machine learning-based model had the highest predictive performance with ROC-AUCs reaching 0.90 for mRS ≤ 2.

CONCLUSION

Machine learning-based evaluation of pc-ASPECTS regions predicts functional outcome of pc-stroke patients with higher accuracy than conventional assessments. This could optimize triage for additional diagnostics and allocation of best possible medical care and might allow required arrangements of the social environment at an early point of time.

Posterior circulation stroke due to vertebral artery disease in the Chinese population

BACKGROUND AND PURPOSE

Little is known about the distribution of the arteries responsible for noncardiogenic posterior circulation stroke due to vertebral artery disease in the Chinese population. Furthermore, few studies have compared the risk factors, imaging manifestations, and outcomes across different types of vertebral artery disease. Therefore, our aim was to compare the differences in the risk factors, imaging manifestations, and outcome across various types of vertebral artery disease.

METHODS

We prospectively enrolled 228 patients from 22 Chinese centers with noncardiogenic posterior circulation stroke due to vertebral artery disease. Vertebral artery disease was classified by the involved segments of the responsible vertebral artery, and basilar artery (BA) involvement or not. Risk factors, clinical-radiologic patterns, and outcomes were compared across different types of vertebral artery disease.

RESULTS

The intracranial vertebral artery (ICVA) was more frequently involved than was the extracranial vertebral artery (ECVA). The ICVA/ICVA + ECVA group more often presented with hypertension and higher systolic blood pressure than did the ECVA group. Compared with the single-segment-of-vertebral-artery group (SSVA), the group with multiple-segments-of-vertebral-artery (MSVA) involvement or SSVA with BA involvement had more serious clinical-radiologic patterns and worse outcomes. Multivariable Cox regression identified MSVA/SSVA + BA involvement as an independent predictor of recurrent ischemic cerebrovascular events.

CONCLUSIONS

The risk factors for ICVA/ICVA + ECVA were different from those of ECVA, and the MSVA/SSVA + BA group had more serious clinical-radiologic patterns and worse outcomes.

Ondine's curse, a fatal infarction diagnosed by polysomnography and saved by ventilation: a case report

Background

Lateral medullary syndrome causing Ondine's curse is a rare yet fatal brainstem infarction. Any patient presenting with lateral medulla infarction ought to be well observed and a polysomnography must be ordered for him.

Case presentation

A patient presenting with Ondine's curse is dealt with through polysomnography as a diagnostic procedure that was followed by tracheostomy with portable ventilator and cardiac pacemaker as a therapeutic maneuver which ultimately preserved his life.

Conclusion

Lateral medullary syndrome infarct could be a life-threatening stroke if not diagnosed and managed properly.

Impact of revascularization therapies on outcome of posterior circulation ischemic stroke: The Indo-US stroke project

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.

Apical pleural aspergillosis with pancoast's syndrome and posterior circulation stroke: a case report

Pancoast's syndrome and subclavian arteritis are rarely caused by Aspergillus sp. . Here we report a case of a 22-yr-old, immunocompetent male who presented with fever, weight loss, right-sided facial anhidrosis and hand weakness of six months duration. Neurological examination confirmed right Horner's syndrome and weakness of small muscles of right hand. Contrast MRI of neck and chest revealed a pleural-based right apical mass abutting subclavian artery and C8-T1 root and multiple enlarged lymph nodes. He developed right hemiataxia due to cerebellar infarct before the planned excision of mass. Surgical exploration showed abscess encasing subclavian artery. Biopsy of the mass resulted in accidental injury of subclavian artery which was repaired. He developed bleeding from suture site postoperatively due pseudo-aneurysm of the subclavian artery which was stented. Histopathology of mass was suggestive of Aspergillus sp. . He was successfully treated with voriconazole. This is probably the first report of Pancoast's syndrome and large vessel angiitis caused by Aspergillus fumigatus which has been successfully managed.

Dynamic compression in vertebral artery dissection in children: apropos of a new protocol

PURPOSE

Our goals are (1) to report a consecutive prospective series of children who had posterior circulation stroke caused by vertebral artery dissection at the V3 segment; (2) to describe a configuration of the vertebral artery that may predispose to rotational compression; and (3) to recommend a new protocol for evaluation and treatment of vertebral artery dissection at V3.

METHODS

All children diagnosed with vertebral artery dissection at the V3 segment from September 2014 to July 2020 at our institution were included in the study. Demographic, clinical, surgical, and radiological data were collected.

RESULTS

Sixteen children were found to have dissection at a specific segment of the vertebral artery. Fourteen patients were male. Eleven were found to have compression on rotation during a provocative angiogram. All eleven underwent C1C2 posterior fusion as part of their treatment. Their mean age was 6.44 years (range 18 months-15 years). Mean blood loss was 57.7 mL. One minor complication occurred: a superficial wound infection treated with oral antibiotics only. There were no vascular or neurologic injuries. There have been no recurrent ischemic events after diagnosis and/or treatment. Mean follow-up was 33.3 months (range 2-59 months). We designed a new protocol to manage V3 dissections in children.

CONCLUSION

Posterior C1C2 fusion is a safe and effective option for treatment of dynamic compression in vertebral artery dissection in children. Institution of and compliance with a strict diagnostic and treatment protocol for V3 segment dissections seem to prevent recurrent stroke.

Acute Dizziness, Vertigo, and Unsteadiness

Vestibular symptoms, including dizziness, vertigo, and unsteadiness, are common presentations in the emergency department. Most cases have benign causes, such as vestibular apparatus dysfunction or orthostatic hypotension. However, dizziness can signal a more sinister condition, such as an acute cerebrovascular event or high-risk cardiac arrhythmia. A contemporary approach to clinical evaluation that emphasizes symptom duration and triggers along with a focused oculomotor and neurologic examination can differentiate peripheral causes from more serious central causes of vertigo. Patients with high-risk features should get brain MRI as the diagnostic investigation of choice.

Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value

BACKGROUND AND PURPOSE

Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke.

METHODS

Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke.

RESULTS

Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission.

CONCLUSION

We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.

Diagnosis of Patients with Acute Dizziness

Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.

Serum miRNA125a-5p, miR-125b-5p, and miR-433-5p as biomarkers to differentiate between posterior circulation stroke and peripheral vertigo

Background

Acute vertigo is a common presentation of inner ear disease. However, it can also be caused by more serious conditions, especially posterior circulation stroke. Differentiating between these two conditions by clinical presentations and imaging studies during the acute phase can be challenging. This study aimed to identify serum microRNA (miRNA) candidates that could differentiate between posterior circulation stroke and peripheral vertigo, among patients presenting with acute vertigo.

Methods

Serum levels of six miRNAs including miR-125a-5p, miR-125b-5p, miR-143-3p, miR-342-3p, miR-376a-3p, and miR-433-5p were evaluated. Using quantitative reverse-transcription polymerase chain reaction (RT-qPCR), the serum miRNAs were assessed in the acute phase and at a 90 day follow-up visit.

Results

A total of 58 patients with posterior circulation stroke (n = 23) and peripheral vertigo (n = 35) were included in the study. Serum miR-125a-5p (P = 0.001), miR-125b-5p (P <  0.001), miR-143-3p (P = 0.014) and miR-433-5p (P = 0.0056) were present at significantly higher levels in the acute phase, in the patients with posterior circulation infarction. Based on the area under the receiver operating characteristic curve (AUROC) only miR-125a-5p (0.75), miR-125b-5p(0.77), and miR-433-5p (0.71) had an acceptable discriminative ability to differentiate between the central and peripheral vertigo. A combination of miRNAs revealed no significant improvement of AUROC when compared to single miRNAs.

Conclusion

This study demonstrated the potential of serum miR-125a-5p, miR-125b-5p, and miR-433-5p as biomarkers to assist in the diagnosis of posterior circulation infarction among patients presenting with acute vertigo.

Separating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing

OBJECTIVE

To separate vestibular neuritis (VN) from posteriorcirculation stroke (PCS) using quantitative tests of canal and otolith function.

METHODS

Video Head-Impulse tests (vHIT) were used to assess all three semicircular canal pairs; vestibulo-ocular reflex (VOR) gain and saccade metrics were examined. Cervical and ocular-Vestibular-Evoked Myogenic Potentials (c- and oVEMP) and Subjective Visual Horizontal (SVH) were used to assess otolith function.

RESULTS

For controls (n = 40), PCS (n = 22), and VN (n = 22), mean horizontal-canal VOR-gains were 0.96 ± 0.1, 0.85 ± 0.3 and 0.40 ± 0.2, refixation-saccade prevalence was 71.9 ± 41, 90.7 ± 57, 209.2 ± 62 per 100 impulses and cumulative-saccade amplitudes were 0.9 ± 0.4°, 2.4 ± 2.2°, 8.0 ± 3.5°. Abnormality-rates for cVEMP, oVEMP and SVH were 38%, 9%, 72% for PCS, and 43%, 50%, 91% for VN. A gain ≤0.68, refixation-saccade prevalence of ≥135% and cumulative-saccade amplitudes ≥5.3° separated VN from PCS with sensitivities of 95.5%, 95.5%, and 81.8%, and specificities of 68.2%, 86.4% and 95.5%. VOR-gain and saccade prevalence when combined, separated VN from PCS with a sensitivity and specificity of 90.9%. Abnormal oVEMP asymmetry-ratios were of low sensitivity (50%) but high specificity (90.9%) for separating VN from PCS.

CONCLUSION

vHIT provided the best separation of VN from PCS. VOR-gain, refixation-saccade prevalence and amplitude were effective discriminators of VN from PCS.

SIGNIFICANCE

vHIT and oVEMP could assist early identification of the aetiology of Acute Vestibular Syndrome in the Emergency Room.

Safety and Efficacy of Intravenous Thrombolytic Therapy in Patients With Acute Posterior Circulation Stroke: A Single-Center Study

BACKGROUND AND PURPOSE

The safety and efficacy of intravenous thrombolytic therapy (IVT) for posterior circulation stroke (PCS) in the real world are rarely studied. This study was designed to evaluate the prestroke and baseline characteristics, stroke sub-types, complications, and outcomes of PCS patients and compare them with anterior circulation stroke (ACS) after intravenous thrombolysis.

METHODS

Data of consecutive patients with PCS and ACS treated with alteplase in a standard dose of 0.9 mg/kg in our stroke center were collected and analyzed retrospectively. Presenting characteristics, hemorrhage transformation, mortality, and favorable outcomes (modified Rankin scale 0 or 1) at 90 days were compared between PCS and ACS patients.

RESULTS

A total of 462 patients were included in this study, including 350 (75.8%) in ACS group and 112 (24.2%) in PCS group. A history of coronary artery disease was significantly more common in ACS patients than that in PCS patients (15.1% versus 6.3%, P = .015). There was no significant difference in fast glucose and baseline NIHSS scores between PCS and ACS groups. In PCS group, 7 patients (6.3%) had hemorrhage transformation after IVT and 5 patients (4.5%) were symptomatic versus 32 (9.1%) and 22 (6.3%) in ACS group (P > .05). 75.5% PCS patients versus 72.2% ACS patients had excellent recovery outcomes (mRS 0-1) at 90 days (P = .507). For PCS patients, logistic regression analysis after adjusting the covariates identified age (P = .047, OR .920, 95% CI = .847-.999) and atrial fibrillation (P = .007, OR 12.149, 95% CI = 1.966-75.093) as independent significant predictors of hemorrhage transformation. In addition, atrial fibrillation was also an independent predictor of symptomatic intracranial hemorrhage (P = .008, OR 21.176, 95% CI = 2.228-201.273). Multivariate logistic analysis identified hemorrhage transformation (P = .012; OR .131, 95% CI = .027-.644) and onset to drug time (P = .026, OR 1.006, 95% CI = 1.001-1.011) as independent predictors of functional independence (mRS 0-2). Symptomatic intracranial hemorrhage (P = .007, OR 15.094, 95% CI = 2.097-108.661) and baseline NIHSS score (P = .050; OR 1.070, 95% CI = 1.000-1.145) were independent predictors of mortality.

CONCLUSION

Our results suggest that IVT in PCS patients is safe and effective as that in ACS patients. In PCS patients, long onset to needle time and hemorrhage transformation were identified as independent predictors of unfavorable outcomes.

Effect of Statin on Stroke Recurrence Prevention at Different Infarction Locations: A Post Hoc Analysis of The J-STARS Study

Aim: Posterior circulation stroke (PCS) has different clinical features and prognosis compared with anterior circulation stroke (ACS), and whether the effect of statin therapy on stroke prevention differs according to infarction location remains unclear. This post hoc analysis of the J-STARS study aimed to compare the usefulness of statin at different infarction locations (i.e., ACS and PCS).

Methods: In the J-STARS study, 1578 patients were randomly assigned to the pravastatin or control group. The subjects were divided into two subgroups (ACS and PCS groups) based on the arteries responsible for the infarction. Cox proportional hazards models were used to investigate whether the all stroke recurrence rate was different between the ACS and PCS groups.

Results: The PCS group (n = 499) had a significantly higher prevalence of diabetes than the ACS group (n = 1022) (30.7% vs. 19.8%, P < 0.001). During the follow-up (4.9 ± 1.4 years), the incidence of all stroke was significantly lower in the pravastatin group than in the control group among patients with PCS (adjusted hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.25–0.83, P = 0.009); however, the stroke recurrence rates were not significantly different between both groups among patients with ACS (adjusted HR 1.32, 95% CI 0.93–1.88, P = 0.123). A significant interaction between the ACS and PCS groups in terms of pravastatin effects was noted (P = 0.003 for interaction).

Conclusions: Pravastatin significantly reduced the recurrence rate of all stroke among patients with PCS. Thus, the effect of statin on the recurrence of stroke may differ according to infarction location.

Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE

Background

Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation.

Methods

We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH).

Results

Median age was 75 years (interquartile range (IQR) 54–81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8–21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1–2) with SAVE and 2 (IQR 1–4) with aspiration (p = 0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort.

Conclusion

Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

Total and differential leukocyte counts in ischemic stroke caused by vertebrobasilar artery dissection

INTRODUCTION

Vertebrobasilar artery dissection(VBD) is a common etiology of posterior circulation stroke(PCS). However, the etiology of VBD itself remains unclear. The present study aimed to test whether inflammation is involved in the mechanism of VBD by evaluating its relationship with total and differential leukocyte counts.

METHODS

Patients with PCS caused by VBD or by large artery atherosclerosis(LAA) were recruited between January 1, 2012 and December 31, 2014 from the Taipei Veterans General Hospital. Age- and sex-matched non-stroke(NS) volunteers were also included. Univariate and multivariate analyses were performed to compare total/differential leukocyte counts among VBD, LAA, and NS groups.

RESULTS

One-hundred-one patients with VBD [average age: 64.8(15.1) years; 77(76.2%) males], 70 with LAA [average age: 73.9(10.6) years; 44(62.9%) males], and 202 NS [average age: 64.8(15.1) years; 77(76.2%) males] patients were included in the present study. Compared with the NS and LAA groups, respectively, the VBD group had significantly higher total leukocyte and neutrophil counts and frequency of high leukocyte (>10,000 × 10⁶/L) and high neutrophil (>8000 × 10⁶/L) counts. Multivariate analyses, adjusted for age, sex, and vascular risk factors, showed that the VBD group, compared with the other groups, had an odds-ratio of 5.04 (95% confidence interval:2.43-10.43) and 5.90 (2.70-12.92) with respect to the prevalence of high leukocyte and high neutrophil counts.

CONCLUSION

VBD was associated with high leukocyte and neutrophil counts. Our results support that inflammation and neutrophil-related pathophysiology might be involved in the mechanism of VBD; however, the causal relationship would need further investigations.

Cerebellar large B-cell lymphoma: a case report

Background

Primary central nervous system lymphoma is a rare, malignant non-Hodgkin lymphoma that can arise in the brain, spinal cord, eye, leptomeninges, or cranial nerves. Primary central nervous system lymphoma is rare, accounting for 2–6% of all primary brain neoplasms and 1–2% of all non-Hodgkin lymphomas, and it usually presents as a solitary lesion. Cerebellar involvement is present in only 9% of cases. We present an unusual case of primary central nervous system lymphoma presenting as multiple lesions in the cerebellum in an immunocompetent host.

Case presentation

A 71-year-old Caucasian man presented to our hospital with acute onset of dizziness, nausea, vomiting, and gait imbalance. Contrast-enhanced computed tomography revealed three intensely enhancing masses in the right cerebellar hemisphere. Whole-body positron emission tomography and computed tomography failed to demonstrate a primary tumor of origin outside the central nervous system. The patient underwent right suboccipital craniotomy with partial resection of the visible tumor from the right cerebellum. Histopathology revealed diffuse large B-cell lymphoma, non-germinal center type.

Conclusions

Primary central nervous system lymphoma is rare, even more so in the cerebellum. However, the overall incidence of primary central nervous system lymphoma is rising in both immunocompromised and immunocompetent patients. The highly aggressive nature of primary central nervous system lymphoma necessitates timely diagnosis and intervention. In this report, we review the available literature for a better understanding of the pathophysiology and management of primary central nervous system lymphoma. To the best of our knowledge, this is the first reported case of a patient with primary central nervous system lymphoma presenting with multiple masses in the cerebellum.

Acute vestibular syndrome: clinical head impulse test versus video head impulse test

HINTS battery involving head impulse test (HIT), nystagmus, and test of skew is the critical bedside examination to differentiate acute unilateral peripheral vestibulopathy from posterior circulation stroke (PCS) in acute vestibular syndrome (AVS). The highest sensitivity component of the battery has been reported to be the horizontal HIT, whereas skew deviation is defined as the most specific but non-sensitive sign for PCS. Video-oculography-based HIT (vHIT) may have an additional power in making the differentiation. If vHIT is undertaken, then both gain and gain asymmetry should be taken into account as anterior inferior cerebellar artery (AICA) strokes are at risk of being misclassified based on VOR gain alone. Further refinement in video technology, increased operator proficiency and incorporation with saccade analysis will increase the sensitivity of vHIT for PCS diagnosis. For the time being, clinical examination seems adequate in frontline diagnostic evaluation of AVS.

Characteristics and Outcomes of Vertebrobasilar Artery Dissection with Accompanied Atherosclerosis

Background

With the popularity of MRI use, vertebrobasilar artery dissection (VBD) has been found more frequently in patients with posterior circulation ischemic stroke (PCS). The relationship between VBD and atherosclerosis is unknown. The present study aimed to prove the hypothesis that PCS with pure VBD (p-VBD) and with VBD and accompanied cervical or cerebral artery atherosclerosis (a-VBD) have distinct manifestations.

Methods

Patients with VBD-related PCS who were prospectively enrolled in the Taipei Veterans General Hospital Stroke Registry between January 1, 2010 and August 31, 2014 were recruited for the present study. Patients who had (1) atherosclerotic plaques with or without stenotic flow in cervical arteries on Duplex ultrasonography or (2) focal >30% stenosis in cerebral arteries other than the dissecting region (usually in arterial bifurcations which are prone to atheroma formation) on brain MRA were defined as a-VBD.

Results

There were 91 patients (67 [73.6%] males, mean age 65.5 years [SD = 15.2, range, 21–91]) with VBD-related PCS recruited for the present study; 31 were a-VBD and 60 were p-VBD. The results showed that there were significant differences in onset age, frequency of cigarette smoking, dissecting vascular involvement, and infarct locations between the 2 groups. In addition, compared with p-VBD, the a-VBD group had poorer functional recovery at 3 months and 1 year, respectively, which was independent of age, sex, vascular risk factors, stroke severity at admission, and treatment options.

Conclusion

VBD-related PCS with and without accompanied atherosclerosis had different manifestations and should be regarded as distinct arterial diseases.

Congenital Bilateral C2 Transverse Foramina Stenosis Causing Adult-Onset Vertebrobasilar Insufficiency and Posterior Circulation Stroke

Vertebrobasilar insufficiency leading to posterior circulation infarcts caused by congenital hypoplasia of the bilateral transverse foramina at the C2 level, affecting the caliber and flow of the bilateral distal cervical vertebral arteries in an adult, has not been previously reported. A 41-year-old male presented with episodic dizziness for a period of 1 year prior to consultation. Computed tomography angiography of the head and neck demonstrated congenital hypoplasia of the bilateral C2 transverse foramina, with absence of the vertebral arteries in each of the foramina and collateral reconstitution of diminutive intracranial vertebral artery segments. Brain MRI showed postinfarction encephalomalacia in the bilateral cerebellar hemispheres. The patient was considered not a surgical or endovascular candidate and was managed conservatively with antiplatelet therapy. Congenital anomalies of the bilateral cervical transverse foramina may present with vertebrobasilar insufficiency and infarction in adulthood.

Prehospital and intra-hospital time delays in posterior circulation stroke: results from the Austrian Stroke Unit Registry

Therapeutic effect of recombinant tissue-plasminogen activator (rt-PA) is time dependent. There is limited evidence whether localization of stroke within the posterior circulation (PCS) is associated with a treatment delay. We aimed to analyze within a nationwide multicenter cohort whether duration of pre- and intra-hospital patient management differs between patients with PCS and anterior circulation strokes (ACS). We studied onset-to-door-times (ODT) and door-to-needle-times (DNT) of all patients with acute ischemic stroke (IS) enrolled in the Austrian Stroke Unit Registry according to infarct localization. Classification into PCS and ACS was based on clinical presentation applying the criteria used in the Oxfordshire Community Stroke Project. Relationships between ODT, respectively, DNT and explanatory variables were modeled by multivariate linear regression. Between 2003 and 2015, 71010 patients with IS were enrolled, 11,924 with PCS and 59,086 with ACS. Overall, the ODT was significantly longer in PCS: median (IQR): 170 (25th, 75th‰: 79,420) min versus 110 (60,240); p < 0.001; this finding held true in multivariable analysis. In 10535 rt-PA-treated patients (1022 PCS/9832 ACS), ODT and DNT were significantly longer among those with PCS: ODT: median: 80 min (55,120) versus 72 (50,110), p < 0.001; DNT: 57 (35.90) versus 45 (30.67), p < 0.001. In the multivariate model, PCS was significantly associated with delay in the DNT. In conclusion, in this large nationwide cohort, patient management was significantly slower in PCS as compared to ACS. Increasing awareness about these delays and further elaboration of the underlying causes may translate into higher proportions of patients with PCS receiving rt-PA.

A New Approach to the Diagnosis of Acute Dizziness in Adult Patients

Dizziness is a common chief complaint in emergency medicine. The differential diagnosis is broad and includes serious conditions, such as stroke, cardiac arrhythmia, hypovolemic states, and acute toxic and metabolic disturbances. Emergency physicians must distinguish the majority of patients who suffer from benign self-limiting conditions from those with serious illnesses that require acute treatment. Misdiagnoses are frequent and diagnostic test costs high. The traditional approach does not distinguish benign from dangerous causes and is not consistent with best current evidence. This article presents a new approach to the diagnosis of acutely dizzy patients that highly leverages the history and the physical examination.

The hyperdense basilar artery sign: a case of locked-in syndrome

Background

Locked-in syndrome, although a notoriously famous clinical entity, the rarity of the condition coupled with the variability of clinical features on acute presentation represents a potential diagnostic pitfall for the emergency physician.

Case

A previously healthy 25-year-old female was brought to our Emergency Department after being found unresponsive. On examination, she was conscious and alert with a Glasgow Coma Score of 9; on neurological examination, the patient was quadriplegic and unable to speak but was able to move her eyes and blink. Non-contrast brain computed tomography (CT) revealed a hyperdense basilar artery, and CT cerebral angiography confirmed basilar artery thrombosis.

Conclusion

This case highlights the need for a high index of suspicion to make a diagnosis of locked-in syndrome in the Emergency Department, especially in young patients with no apparent risk factors for an ischemic stroke. The hyperdense basilar artery sign is one of the earliest signs on non-contrast CT imaging and may be the only clue to guide further management in a patient with basilar artery occlusion.

Acute Vertebrobasilar Territory Infarcts due to Heat Stroke

Heat stroke is common in tropical country like India especially during the summer season. We report an unusual case of acute vertebrobasilar territory infarcts due to heat stroke. A middle-aged man developed hyperpyrexia (42.2°C) after strenuous fieldwork in a hot summer day. Next morning, he was found in altered sensorium. The brain imaging showed acute posteromedial midbrain and cerebellar infarcts. A diagnosis of acute ischemic stroke due to heat stroke was made, and the patient was put under the intensive care unit. Two weeks later, the patient became conscious, but had slurred speech and incoordination in all the 4 limbs. Six months after rehabilitation, the patient still have scanning speech and limb ataxia. Acute ischemic stroke worsened the prognosis in our patient. Acute infarct is a very rare neurologic manifestation of heat stroke. This case report emphasizes the importance of suspecting acute infarct in heat stroke patient.