Posterior Circulation Ischemic Stroke Research Articles

Prognostic value of the baseline magnetic resonance score in patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy

To investigate the prognostic value of the composite posterior circulation Acute Stroke Prognosis Early Computed tomography (CT) Score (ASPECTS)-Collaterals (pcASCO) score, which combines diffusion-weighted imaging (DWI) posterior circulation ASPECTS (pcASPECTS) and the magnetic resonance angiography (MRA)-collateral circulation score at baseline among patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy. Patients with acute posterior circulation ischaemic stroke who underwent mechanical thrombectomy were analysed retrospectively. The DWI-pcASPECTS and MRA-collateral circulation score before treatment and the modified Rankin Scale (mRS) at 90 days after treatment were used as the endpoints. An mRS ≤2 was defined as a good prognosis, and an mRS ≥3 was defined as a poor prognosis. Multivariate logistic regression was used to analyse independent predictors of functional outcome 90 days after mechanical thrombectomy. Mechanical thrombectomy was performed in 57 patients; 38 patients had a good prognosis, 19 patients had a poor prognosis, and 33 patients were successfully recanalised. Univariate logistic regression found that National Institute of Health Stroke Scale (NIHSS) score (OR: 1.18, p<0.001), pcASPECTS (OR: 1.91, p=0.028) and pcASCO score (OR: 0.51, p=0.001) were factors of good functional outcome. Receiver operating characteristic curve (ROC curve) analysis showed that the diagnostic efficiency of the NIHSS and pcASCO was better (AUC=0.88, 0.83, p<0.05) than that of the pcASPECTS (AUC=0.65). The prediction model was established by age, NIHSS, and pcASCO, and the diagnostic efficiency of the prediction model was better (AUC=0.94). The composite MR-pcASCO score can be used as an important predictor of the prognosis of patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy.

Comparing Functional Outcomes and Safety Profiles of First-Line Aspiration Thrombectomy Versus Stentriever for Acute Basilar Artery Occlusion: Propensity Analysis of the PC-SEARCH Thrombectomy Registry.

Aspiration catheters (ASPs) and stentriever thrombectomy devices have comparable safety and efficacy in anterior circulation ischemic strokes. However, there is lack of high-quality comparative data in acute basilar artery occlusions. Our objective is to compare the outcomes and safety of ASPs and stentriever devices in acute basilar artery occlusions. This is an analysis of the retrospectively established PC-SEARCH Thrombectomy (Posterior-Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy) registry. Patients were dichotomized based on their first-line thrombectomy device (ASP and stentriever) and associated with their 90-day functional outcomes, intraprocedural metrics, and safety measures. Propensity analysis based on unequal baseline characteristics was performed. Consecutive patients with acute basilar artery occlusions who received mechanical thrombectomy were included from January 2015 to December 2021. Patients received either first-line contact aspiration or stentriever mechanical thrombectomy. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale score of 0 to 3 and symptomatic intracranial hemorrhage, respectively. Secondary outcomes included puncture-recanalization times, first-pass recanalization rates, crossovers to other thrombectomy device, and neurological/hospital complications. Five hundred eighteen patients were included in the registry, and a total of 383 patients were included (mean [SD] age, 65.5 [15] years; 228 [59%] men) in this analysis. Of these, 219 patients were first-line ASP while 164 patients received first-line stentriever devices. Median premorbid modified Rankin Scale was zero and median presenting National Institutes of Health Stroke Scale was 17 (interquartile range, 8-26). The proportion of favorable functional outcome was similar between the 2 techniques before (47.3% versus 42.5%; odds ratio, 1.22 [95% CI, 0.78-1.89]; P=0.38) and after propensity matching (odds ratio, 1.46 [95% CI, 0.85-2.49]; P=0.17). In our propensity-matched cohorts, puncture-recanalization times (18 versus 52 minutes; P<0.01) favored first-line ASP; however, first-pass recanalization rates (43.5% versus 44.5%; P=0.90) were similar between groups. First-line ASP was associated with higher rates of crossover (22% versus 6%; P<0.01), whereas stentriever was associated with higher rates of symptomatic intracranial hemorrhage (9.8% versus 3.4%; P=0.04). First-line ASP and stentriever methods demonstrated similar functional outcome and recanalization rates. Stentriever methods were associated with higher rates of symptomatic intracranial hemorrhage, whereas ASPs were associated with higher rates of crossover to alternative technique in patients with acute basilar occlusions.

A Case of Delayed Audiovestibulopathy after Posterior Circulation Ischemic Stroke

Distinguishing central and peripheral causes of dizziness is vital. A case is presented where a 42-year-old man with a history of posterior circulation ischemic stroke developed acute unilateral vestibulopathy with hearing loss. Clinical examination revealed signs of vestibular dysfunction on the left side. Audiometry confirmed deafness on the left, but imaging ruled out new central issues. The patient was diagnosed with audiovestibulopathy and treated with steroids, antiviral agents, intratympanic injections, and hyperbaric oxygen therapy. Hearing loss persisted, but dizziness improved with vestibular rehabilitation. Poststroke patients should be closely monitored for peripheral complications. Further research should explore the benefits of antiplatelet therapy in vascular-related conditions, even without clear central lesions.

Association between vertebrobasilar artery geometry and vertebrobasilar stenosis, recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA. MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed. ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010). ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.

Imaging features of vertebrobasilar dolichoectasia combined with posterior circulation ischemic stroke: A vessel wall magnetic resonance imaging study

PurposeTo elucidate the vessel wall changes of vertebrobasilar dolichoectasia (VBD) with ischemic stroke, using vessel wall magnetic resonance imaging (VW-MRI). MethodThirty-four patients with VBD (22 with stroke and 12 without stroke) who underwent VW-MRI were recruited. Forty-one patients without VBD who underwent VW-MRI were also recruited if they had a recent stroke due to atherosclerosis in the basilar artery or the intracranial vertebral artery. The vessel wall features of VBD were compared between stroke and non-stroke groups. The plaque characteristics were compared between VBD and non-VBD stroke patients. ResultsThe frequency of plaques was higher (54.5% vs. 8.3%, P = 0.011) in VBD patients with stroke than that in non-stroke patients, while the frequencies of aneurysm, dissection, intraluminal thrombus, and diffuse/concentric wall enhancement did not differ. When the plaque features were compared between plaque-positive stroke patients with and without VBD, the degree of stenosis (31.0% ± 26.8% vs. 71.5% ± 19.0%, P < 0.001), normalized wall index (NWI) (0.7 ± 0.1 vs. 0.9 ± 0.1, P < 0.001), and remodeling index (RI) (1.0 ± 0.4 vs. 1.3 ± 0.4, P = 0.023) were lower in the VBD group, while intraplaque hemorrhage, and enhancement ratio showed no difference. ConclusionsThis preliminary study suggests that atherosclerosis may be an important cause of stroke in VBD patients. Symptomatic plaques in VBD patients have a lower degree of stenosis, NWI, and RI than that in non-VBD patients. VW-MRI may help to assess stroke mechanisms and identify VBD patients at high risk.

Subacute Sclerosing Panencephalitis Mimicking Posterior Circulation Ischemic Stroke

Abstract Subacute sclerosing panencephalitis (SSPE) is a progressive neurodegenerative disease that develops 2–10 years after a measles infection. The diagnosis is possible through history, electroencephalography findings, and measles antibodies in the cerebrospinal fluid. Magnetic resonance imaging (MRI) is also an assistive tool in the diagnosis. The typical presentation of the disease on MRI is the bilateral, asymmetric lesions in the periventricular and subcortical areas. Brainstem involvement is uncommon. We describe a 12-year-old boy who was initially diagnosed with posterior circulation ischemic stroke with left cerebellar peduncle diffusion restriction, treated with low molecular weight heparin, and later found to have SSPE. His follow-up MRI in 2 months showed massive cerebral cortical and white matter destruction although his first MRI with cerebellar peduncle diffusion restriction initially revealed almost normal cerebral cortex and white matter. Brainstem involvement with diffusion restriction helps expand the radiological spectrum of SSPE.

A clinical comparative analysis between expanded NIHSS and original NIHSS in posterior circulation ischemic stroke

BackgroundThe NIHSS is used routinely but has drawbacks. One of them is its inefficiency in detecting all signs of posterior circulation strokes. Since its declaration as a possible substitute for NIHSS in posterior circulation strokes in 2016; the expanded NIHSS (e-NIHSS) has not been paid much attention.The current study assesses clinically the value of e-NIHSS over NIHSS in posterior circulation strokes as regards the percentage of cases with different/higher scores, the significance of such scoring on management decisions, the weight of baseline e-NIHSS as a prognostic tool on 90 days functional outcome and its cut off value. MethodsThe current longitudinal observational study was conducted on 79 cases after formal written consent who presented with posterior circulation strokes and confirmed by brain imaging. ResultsIn Comparison to NIHSS; the e-NIHSS score was higher in 36 cases at baseline and in 30 cases on discharge. The e-NIHSS median was two points higher at baseline and 24 h and was one point higher on discharge P < 0.001. A baseline moderate/moderate-severe was more common with e-NIHSS (n 50, 63.3%). In terms of 90 days outcome; a less favorable outcome (>2) was evident in cases with different scoring (e-NIHSS > NIHSS) indicating more sensitivity of e-NIHSS in prognosing 90 days outcome. ROC curve showed 82% sensitivity and 81% specificity with a significant area under the curve (=0.858) on scoring ≥ 8 in e-NIHSS. Conclusione-NIHSS is diagnostically and prognostically relevant tool in posterior circulation strokes and ought to be considered in future guidelines.

The Writing is on the Wall - Interesting Case of Peduncular Hallucinosis in an Adult Patient (P12-5.006)

<h3>Objective:</h3> Showcase an atypical presentation of peduncular hallucinosis (PH) amenable to vertebral artery stenting. <h3>Background:</h3> PH is a visual hallucination of non-stereotypical and naturalistic images. Although the pathophysiology of PH is unknown, specific brain lesions or neurotransmitter disequilibrium could cause PH. PH is diagnosed clinically however imaging helps rule out structural causes. <h3>Design/Methods:</h3> NA <h3>Results:</h3> 70-year-old man with migraine with an aura of scotoma and strabismus initially presented with hallucination status-post atrial fibrillation ablation. He reported 45 minutes of seeing vivid yellow numbers and colors throughout his vision. Imaging demonstrated no acute infarct. After discharge, he developed recurrent, intermittent, unprovoked, and acephalgic hallucinations of vivid, colorful, and patternless numbers and letters. Though typically brief (1–5 minutes), some lasted an hour. His migrainous auras were different; a pre-cephalgic scotoma and “cellophane” photopsia. Physical examination was unremarkable except baseline strabismus. He returned one week after discharge with acute cervicalgia and vertigo. Head and neck MRA found a chronic occluded right vertebral artery with collateral filling. He was discharged on aspirin, plavix, and a high-intensity statin. Two months later, the patient returned with transient vertigo and right-sided weakness with similar visual hallucinations. MRI brain demonstrated accumulating posterior circulation ischemic stroke burden (acute and subacute infarcts) and CTA redemonstrated right vertebral occlusion but revealed severe short-segment stenosis of the left vertebral artery seen on prior imaging in retrospect, confirmed by digital subtraction angiography. After failure of maximal medical management, he underwent balloon-inflated coronary stenting with no recurrence of hallucinations or transient vascular symptoms despite post-procedural thalamic hemorrhage. <h3>Conclusions:</h3> Due to limited cases and unknown pathophysiology, further research on PH is required to discover the underlying causality and proper treatment. This case highlights an initially overlooked short-segment vertebral artery stenosis that, after failure of maximal medical management, was stented and provided complete relief from hallucination <b>Disclosure:</b> Mr. Suvarna has nothing to disclose. Ms. Shams has nothing to disclose. Dr. Broderick has nothing to disclose.

Thrombectomy and Stenting Management in Basilar Artery Occlusion Associated with Acute Stroke Case Report: Important Role of Radiology for Diagnostic and Treatment

Occlusions of the basilar artery (BA), which are typically caused by thromboembolism and atherosclerosis, may account for as much as 27% of posterior circulation ischemic strokes. The symptoms of BA occlusion can range from temporary weakness or paraesthesia to near-complete paralysis, leading to a high risk of morbidity and mortality. CT and MRI are the imaging modalities of choice for identifying and locating the infarct area, ruling out any other lesions, and detecting vascular abnormalities. The combination of thrombectomy and stenting has been shown to increase the safety and durability of angioplasty without causing noticeably negative side effects, and it may be utilized as the first line of treatment for BA stenosis or occlusion in acute stroke.

Palatal myoclonus and hypertrophic olivary degeneration following wernekinck commissure syndrome: a case report

BackgroundHypertrophic olivary degeneration (HOD), a rare form of transsynaptic degeneration, is secondary to dentato-rubro-olivary pathway injuries in some cases. We describe a unique case of an HOD patient who presented with palatal myoclonus secondary to Wernekinck commissure syndrome caused by a rare bilateral “heart-shaped” infarct lesion in the midbrain.Case presentationA 49-year-old man presented with progressive gait instability in the past 7 months. The patient had a history of posterior circulation ischemic stroke presenting with diplopia, slurred speech, and difficulty in swallowing and walking 3 years prior to admission. The symptoms improved after treatment. The feeling of imbalance appeared and was aggravated gradually in the past 7 months. Neurological examination demonstrated dysarthria, horizontal nystagmus, bilateral cerebellar ataxia, and 2–3 Hz rhythmic contractions of the soft palate and upper larynx. Magnetic resonance imaging (MRI) of the brain performed 3 years prior to this admission showed an acute midline lesion in the midbrain exhibiting a remarkable “heart appearance” on diffusion weighted imaging. MRI after this admission revealed T2 and FLAIR hyperintensity with hypertrophy of the bilateral inferior olivary nucleus. We considered a diagnosis of HOD resulting from a midbrain heart-shaped infarction, which caused Wernekinck commissure syndrome 3 years prior to admission and later HOD. Adamantanamine and B vitamins were administered for neurotrophic treatment. Rehabilitation training was also performed. One year later, the symptoms of this patient were neither improved nor aggravated.ConclusionThis case report suggests that patients with a history of midbrain injury, especially Wernekinck commissure injury, should be alert to the possibility of delayed bilateral HOD when new symptoms occur or original symptoms are aggravated.

Outcomes of Endovascular Treatment for Posterior Circulation Stroke According to the Underlying Pathologic Mechanism: A Retrospective Single-Center Analysis

Objectives. This study investigated the functional outcomes and safety of endovascular treatment in patients with posterior circulation stroke according to whether the underlying mechanism was arterial embolism or intrinsic atherosclerosis. Materials and Methods. A total of 108 consecutive patients with posterior circulation ischemic stroke who received endovascular treatment between January 2018 and December 2021, 58 with arterial embolism and 50 with intrinsic atherosclerosis, were identified. The overall and basilar artery occlusion subgroup analyses were retrospectively conducted between the two study groups using a logistic regression model. Results. The rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b–3) was comparable in the embolism versus intrinsic group (96.6% versus 90.0%; adjusted odds ratio [aOR] 0.73, 95% confidence interval [CI] 0.01–42.74; P = 0.88 ). There was no significant difference in the frequency of a moderate outcome between the two groups (modified Rankin Scale [mRS] score 0–3: 43.1% versus 58.0%; aOR 0.63, 95% CI 0.15–2.50; P = 0.51 ), frequency of a favorable outcome (mRS 0–2: 39.7% versus 38.0%; aOR 1.59, 95% CI 0.37–6.70; P = 0.52 ), the 90-day mortality rate (34.5% versus 26.0%; aOR 2.31, 95% CI 0.50–10.63; P = 0.28 ), or frequency of symptomatic intracranial hemorrhage (6.9% versus 2.0%, respectively; P = 0.37 ). The subgroup analysis in patients with basilar artery occlusion found no significant between-group difference in any of the abovementioned clinical outcomes (all P &gt; 0.05 ). Conclusion. This study indicated that the mechanism of posterior circulation stroke had no significant effect on the functional outcomes after endovascular treatment or on procedural safety.

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

BackgroundThe incidence, risk factors, and pathogenesis of early neurological deterioration (END) in posterior circulation stroke are still unclear. In this study, we aimed to determine the risk factors and prognosis of END in patients with acute posterior circulation cerebral infarction. MethodsAcute posterior circulation ischemic stroke patients who had completed neuroimaging within 72 h of onset were selected from a prospective registry studyDemographic characteristics, physiological data, medical history, laboratory data, in-hospital evaluation, neurological severity and TOAST classification, treatment, and the modified Rankin Scale (mRS) score of patients were assessed. Early neurological deterioration was defined as an increase of 2 points in the National Institutes of Health Stroke Scale score between the baseline and 72 h evaluation. Favorable and poor outcomes were defined as mRSs of 02 and≥ 3, respectively, at 3 months. The incidence and risk factors were evaluated by univariate and multivariate regression analysis (step-back method). ResultsThe analysis included 455 subjects with an acute posterior circulation non-cardiac ischemic stroke, 330 (72.53 %) of them male, with an average age of 63.12 ( ± 10.14) years and with 47 (10.33 %) having END. The results of univariate and multivariate logistic regression analysis showed that BATMAN scores ≥ 5 (OR: 0.1, 95 % CI: 0.02–0.53, P < 0.01), large artery atherosclerosis (OR: 11.55, 95 % CI: 4.18–31.93, P < 0.01), vascular stenosis > 50 % (OR: 2.44, 95 % CI: 1.1–5.42, P = 0.029), reperfusion therapy (OR: 4.21, 95 % CI: 1.66–10.64, P < 0.01), and the distribution of pontine lesions (OR: 5.66, 95 % CI: 2.39–13.44, P < 0.01) were significantly associated with END. Patients with END had a lower rate of favorable outcomes at discharge and long-term follow-up (P < 0.001), regardless of whether they received reperfusion therapy. ConclusionThe lesion distribution of the pons, the progression of temporo-occipital lobe lesions, and large arterial atherosclerosis are independent risk factors of END that might predict a poor short- and long-term prognosis.

Basilar artery plaque distribution is associated with pontine infarction and vertebrobasilar artery geometry.

Basilar artery (BA) atherosclerosis is a common cause of posterior-circulation ischemic stroke. In this study, we investigate the relationship between BA plaque distribution and pontine infarction (PI), further, explore the influence of vertebrobasilar artery (VBA) geometries on BA plaque distribution. 303 patients were performed with MRI in this study, patients were divided into three groups: no cerebral infarction (NCI), anterior circulation cerebral infarction (ACCI), and posterior circulation cerebral infarction (PCCI), the VBA geometry was classified into four configurations: Walking, Tuning Fork, Lambda, and No Confluence. The AP-Mid-BA, Lateral-Mid-BA, and VA-BA angles were measured on three-dimensional time-of-flight magnetic resonance angiography. Patients underwent high-resolution magnetic resonance imaging to evaluate the BA plaque distribution (either anterior, posterior, or lateral wall). Acute and subacute cerebral infarction [including pontine infarction (PI)] were identified by T2 weighted imaging-fluid-attenuated inversion recovery and diffusion-weighted imaging. The presence of BA plaque (P < 0.001) were associated with PCCI. Eighty-six patients all with BA plaque were further analyzed, compared with patients without pontine infarction, patients with pontine infarction were more likely to have plaque distributed at the posterior wall (P = 0.009) and have larger VA-BA anger (38.72° ± 26.01° vs. 26.59° ± 17.33°, P = 0.035). BA plaques in patients with pontine infarction were more frequently located at the posterior wall (50.00%) than at the anterior (10.00%) and lateral (37.50%) walls (P = 0.028). In Walking, Lambda and No Confluence geometry, BA plaques were prone to located at the lateral wall than at the anterior and posterior walls (all P ≤ 0.05). In the Tuning Fork group, BA plaques were evenly distributed. BA plaque was related to PCCI, BA plaque distribution was associated with PI, and VBA configuration strongly influences BA plaque distribution.

Abstract Number ‐ 268: Sarcoid Induced Posterior Circulation Abnormality With Recurrent Ischemic Strokes

Introduction The estimated incidence of Neurosarcoidosis is ∼5‐15%. Most of these cases involve anterior circulation. Here we are presenting a case of recurrent posterior circulation ischemic stroke in a patient with neurosarcoidosis. Methods A 41‐year‐old Male had biopsy proven sarcoidosis diagnosed in 2012 with pulmonary involvement. He was on chronic low dose Corticosteroid. In 2014, he presented with right pontine ischemic infarction causing left‐sided hemiplegia. He underwent extensive workup including conventional angiogram that showed irregular intracranial left vertebral artery with mild narrowing distal to posterior inferior cerebellar artery (PICA) and mild dilatation proximal to basilar artery (Image on the top). He was started on Aspirin 81 mg. In 2021, he had a right inferior cerebellar peduncle infarction with repeat angiogram showing abnormal dysplastic dilatation of the left vertebral artery at V4 segment and the top of basilar artery that has progressed since 2014 (image on the bottom). Workup showed that he was Aspirin non‐responder and has been switched to Clopidogrel. Results The most common presentation of neurosarcoidosis is cranial neuropathy, mostly facial nerve. Ischemic stroke is one of the uncommon presentation of neurosarcoidosis. The likely mechanism could begranulomatous invasion of the blood vessel wall with vasculitic disruption of the media and internal elastic lamina. Conclusions To our knowledge, this is a rare case of neurosarcoidosis progressively affecting posterior circulation causing recurrent stroke.

Posterior circulation ischaemic stroke - A retrospective analysis from a General Hospital

Posterior circulation ischaemic stroke - A retrospective analysis from a General Hospital

Posterior Circulation Ischemic Stroke in Association with Vertebral Artery Duplication: A Case Report and Review of Literature.

Posterior Circulation Ischemic Stroke in Association with Vertebral Artery Duplication: A Case Report and Review of Literature.

Physiotherapy Rehabilitation in Cerebellar Stroke: A Case Study

Cerebellar stroke presents a challenging task for rehabilitation. The patient in this case study was a 61-year-old man with a diagnosis of posterior circulation ischaemic stroke. He was referred to our physiotherapy outpatient unit in a major tertiary hospital in Nigeria about two years ago. Patient could not sit up from lying, nor stand or walk independently. Visible and palpable tremors were observed in the entire body but more pronounced in the head, neck and shoulders (titubation). Patient could not perform self-care activities; there was difficulty with speech, language and communication. The treatment included free active exercises, mat exercises, bridging, rolling and sitting and standing balance training, breathing exercises, bicycling, walking within parallel bars, wobble board, facial massage, strengthening exercises, cervical collar use and home programme. Involved repetition of treatment session activities taught to his caregivers who were ascertained competent to effect. Treatment was structured into short term and long term goals. Treatment sessions were initially given twice daily, then once weekly and later once monthly, as the patient gained control, confidence and independence. After 68 sessions of treatment spanning almost 2 years, the patient had gained independent walking, improved quality of life, and in particular titubation disappeared.

Post COVID-19 ischemic stroke in a 15-Year-old patient.

Coronavirus disease 2019 (COVID-19) has been reported in the literature to be associated with a higher risk of stroke in young individuals with no previous risk factors. We present here one such case of a 15-year-old girl with posterior circulation ischemic stroke resulting in dense right hemiplegia and cerebellar incoordination. The patient tested positive for COVID-19 infection without displaying any symptoms of active COVID-19 infection at the time of the stroke. An MRI brain scan showed acute infarcts in the pons and left cerebellar hemisphere, and a CT angiogram of the cerebrovascular system showed occluded left vertebral and basilar arteries.The most salient feature of this case is COVID-19 infection manifesting clinically as cerebrovascular thrombosis in an otherwise healthy young girl with no pre-existing comorbidities and no laboratory findings of coagulopathy except for mildly elevated D-dimer.

Clinical Profile of Posterior Circulation Stroke: A Prospective Study at Dhaka Medical College Hospital

Studies regarding clinical characteristics of stroke involving the posterior circulation territory of the brain in Bangladesh are rare although large number of patients were found in hospital admission and with a high morbidity and mortality. Study for better understanding of the clinical features, risk factors and aetiologies of posterior circulation stroke (PCS) may be very helpful for early diagnosis, treatment, and also for setting primary and secondary prevention strategies. The objective of the study was to identify clinical features and short-term outcome of PCS. Adult patients admitted in Dhaka Medical College Hospital with clinical features consistent with posterior circulation stroke involving brain stem or, cerebellum or thalamus or occipital area and confirmed by computer tomography (CT) scan of brain were the the cases as respondents. Few cases were needed MRI of brain to confirm diagnosis. This was a hospital based prospective observational study with descriptive and analytical component. Sample was selected from the study population by purposive type of non-probability sampling technique. Sample size was 30. A semi-structured questionnaire was prepared containing patients’ profile as well as stroke patients’ reporting form which included all the essential information regarding clinical profile of PCS as well as short term outcome. Analysis was done using Statistical Package for the Social Sciences (SPSS) software. Thirty consecutive cases of strokes involving posterior circulation territory were included in the study according to inclusion and exclusion criteria. Male female ratio was 1.7:1. Most of the patients in both sexes were affected after the age of 50 years. Hemorrhagic PCS was significantly higher than ischaemic PCS. Among hemorrhagic PCS common symptoms were decreased level of consciousness and motor disturbances. Most common clinical sign in ischemic PCS is impaired consciousness which was present in 55.6% of the total ischemic PCS cases. Whereas this sign was present in all the cases of hemorrhagic PCS (100%). Like presenting symptoms, most of the clinical signs were also more common in hemorrhagic PCS. But few clinical signs were more common in ischemic strokes, such as cranial nerve involvement and nystagmus. Commonest predisposing factors were tobacco abuse, hypertension and dyslipidemia. Mortality was higher in hemorrhagic PCS than ischemic PCS within 7 days of follow up.&#x0D; Bangladesh Med J. 2021 Sept; 50(3): 20-25

Clinical Case 17—A catastrophic case of ischemic stroke and acute myocarditis in a young patient following mRNA COVID-19 vaccination: coincidence or consequence?

Abstract A healthy 32-years-old man was admitted in emergency department after cardiac arrest at home. He had complaints of fatigue and general malaise after Pfizer-BioNTech Coronavirus disease-2019 (COVID-19) first dose vaccine 48 hours earlier. Upon hospital admission, patient scored 3 points in Glasgow Coma Scale. Electrocardiogram showed atrial fibrillation with rapid ventricular response and a point-of-care ultrasound demonstrated severe left ventricular dysfunction with global hypokinesia. Blood tests were remarkable for elevation of high-sensitivity cardiac troponin-T and inflammatory parameters, normal platelet and fibrinogen levels and slightly increased D-dimer. A computed tomography (CT) with angiography of the cerebral arteries revealed acute ischemic posterior circulation stroke with total occlusion of the basilar artery and partial occlusion of the left vertebral artery. Life-saving systemic thrombolysis was performed but there was no clinical benefit. Pulmonary embolism was excluded. Transesophageal echocardiography showed severe left ventricular dysfunction (LVEF 30%), global hypokinesia and an apical thrombus with no other significant abnormalities. De novo multiple ischemic injuries were shown in 24h control brain CT. Once autoimmunity, thrombophilia study, PCR and serologic tests for viral infections including SARS-CoV-2 were negative, cardioembolic stroke following post-vaccinal myocarditis was suspected. Brain stem death was verified 72h later and a post-mortem endomyocardial biopsy was performed, although no signal of myocarditis was found. COVID-19 mRNA vaccination is associated with increased risk of myocarditis. We report the first known case of cardioembolic stroke and probable myocarditis after BNT162b2 first dose. This highlights that, although rare and with a predominantly favorable course, vaccine-related myocarditis can have life-threatening complications. Figure 1Apical left ventricle thrombus on transesophageal echocardiography.