Posterior Circulation Ischemia Research Articles

Characterization of posterior circulation blood perfusion in patients with different degrees of basilar artery tortuosity.

The morphology of basilar artery (BA) may affect posterior circulation blood perfusion. We aimed to investigate whether different degrees of BA tortuosity could lead to the alterations of posterior circulation perfusion. We collected 138 subjects with different BA tortuosity scores, including 32 cases of score 0, 45 cases of score 1, 43 cases of score 2, and 18 cases of score 3. A higher score represented a higher degree of BA tortuosity. Ordered logistic regression analysis was performed to investigate the risk factors for BA tortuosity. We quantitatively measured the cerebral blood flow (CBF) in eight posterior circulation brain regions using arterial spin labeling. SPSS 25.0 was used for statistical analysis. The correlation between the CBF and BA tortuosity was corrected by the Bonferroni method. The significance level was set at 0.006 (0.05/8). Hypertension (HR: 2.39; 95%CI: 1.23-4.71; P = 0.01) and vertebral artery dominance (HR: 2.38; 95%CI: 1.10-4.67; P = 0.03) were risk factors for BA tortuosity. CBF in occipital gray matter (R = -0.383, P < 0.001), occipital white matter (R = -0.377, P < 0.001), temporal gray matter (R = -0.292, P = 0.001), temporal white matter (R = -0.297, P < 0.001), and cerebellum (R = -0.328, P < 0.001) were negatively correlated with BA tortuosity degree. No significant correlation was found between the BA tortuosity degree and CBF in hippocampus (R = -0.208, P = 0.014), thalamus (R = -0.001, P = 0.988) and brainstem (R = -0.204, P = 0.016). BA tortuosity could affect posterior circulation blood perfusion. CBF was negatively correlated with BA tortuosity degree. The morphology of BA may serve as a biomarker for posterior circulation and the severity of posterior circulation ischemia.

Comprehensive evaluation of the mechanism of Banxia Baizhu Tianma Decoction in ameliorating posterior circulation ischemia vertigo based on integrating fecal short-chain fatty acids and 16S rRNA sequencing

Posterior circulation ischemia vertigo (PCIV) is vertebrobasilar insufficiency resulting in vertigo. Banxia Baizhu Tianma Decoction (BBTD) is broadly applied to treat PCIV in China, but its efficacy and detailed mechanism remains unclear. Therefore, this study aims to investigate the effects of BBTD on PCIV, and identify important gut microbiota and its derived short-chain fatty acid (SCFA) changes and the detailed mechanism through 16 S rRNA sequencing with SCFAs profiling. In this study, the model of PCIV was established by surgical ligation of the right subclavian artery (RSCA) and right common carotid artery (RCCA). We found that BBTD administration effectively reduced the volume of cerebral infarction and improved neurologic functions, reduced neuronal apoptosis and neuroinflammatory. Moreover, BBTD significantly modulated the diversity and composition of the gut microbiota, including increasing the relative abundance of Lactobacillus, Prevotella and Akkermansia and decreasing relative abundances of Lachnospiraceae, Bacteroidetes (S24–7) and Ruminococcaceae. BBTD treatment also increased propionate content. Propionate mediates the the recovery of neurological functions and anti-apoptotic effects of BBTD in PCIV rat. Our findings wish to discover the potential mechanism of BBTD treatment on PCIV and promote its clinical application.

Application of 3D-PCASL combined with t-ASL and MRA in the diagnosis of patients with isolated vertigo induced by posterior circulation ischemia

ObjectivesIsolated vertigo induced by posterior circulation ischemia (PCIV) can further progress into posterior circulation infarction. This study aimed to explore the diagnostic values of three-dimensional pseudo-continuous arterial spin labeling (3D-PCASL) combined with territorial arterial spin labeling (t-ASL) and magnetic resonance angiography (MRA) in visualizing and evaluating PCIV, seeking improved diagnostic tools for clinical guidance. Methods28 PCIVs (11 males, 17 females, aged from 55 to 83 years, mean age: 69.68 ± 9.01 years) and 28 healthy controls (HCs, 12 male, 16 female, aged from 56 to 87 years, mean age: 66.75 ± 9.86 years) underwent conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), MRA, 3D-PCASL, and t-ASL. We compared the incidence of anatomic variants of the posterior circle of Willis in MRA, cerebral blood flow (CBF) and anterior collateral blood flow on postprocessing maps obtained from 3D-PCASL and t-ASL sequence between PCIVs and HCs. Chi-square test and paired t-test were analyzed statistically with SPSS 24.0 software. Results7 PCIVs (7/28, 25%) and 6 HCs (6/28, 21%) showed fetal posterior cerebral artery (FPCA) on MRA, including 1 HC, and 6 PCIVs with FPCA appeared hypoperfusion. 18 PCIVs (64%) and 2 HCs (7%) showed hypoperfusion in the posterior circulation (PC), including 1 HC and 7 PCIVs displayed anterior circulation collateral flow. Chi-square analyses demonstrated a difference in PC hypoperfusion between PCIVs and HCs, whether in the whole or FPCA-positive group assessment (P < 0.05). Paired t-test showed that the CBF values were significant difference for the bilateral PC asymmetrical perfusion in the PCIVs (P < 0.01). When compared to the bilateral PC symmetrical non-hypoperfusion area in the PCIVs and HCs, the CBF values were not significant (P > 0.05). The CBF values of the PC in PCIVs were lower than in HCs (P < 0.05). The reduction rate in the hypoperfusion side of the bilateral PC asymmetrical perfusion of the PCIVs ranged from 4% to 37%, while the HCs reduction rate was 7.7%. The average PC symmetrical perfusion average reduction rate of the PCIVs was 52.25%, while the HCs reduction rate was 42.75%. Conclusion3D-PCASL is a non-invasive and susceptible method for detecting hypoperfusion in PC, serving as a potential biomarker of PCIV. The suspected hypoperfusion in PC may be attributed to the emergence of FPCA and the manifestation of anterior collateral flow when combining t-ASL and MRA sequences. These findings demonstrated that 3D-PCASL combined with t-ASL and MRA sequences are the potential method to identify PCIV, leading to early diagnosis of PCIV and reducing the risk of progressing into infarction.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

End-to-end revascularization between the occipital Artery(OA) and the p1 segment of posterior inferior cerebellar Artery(PICA) for a patient with posterior circulation ischemia via a far-lateral approach:2-Dimensional Operative video

Vertebral artery （VA）Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) ,occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis. At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa. Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops , aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead. This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. The operation proved the feasibility of end-to-end bypass in OA-p1 PICA.

Abstract TP252: Forward Head Posturing as a Significant Risk Factor for Posterior Circulation Infarcts

Objective: Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke. Methods: We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference. Results: 76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03). Conclusion: In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Abstract TP119: Predicting Posterior Circulation Stroke During Emergency Triage: Dizzy-7 Project

Introduction: “Stroke code” activation is a uniform process to summon healthcare stakeholders to orchestrate the rapid sequential steps for urgent management in patients with possible stroke. Acute dizziness, a common emergency department (ED) presentation, frequently leads to stroke code activation; however, cancellation rates remain high and process improvement strategies are warranted. Methods: We analyzed stroke identification accuracy, cancellation rates, and clinical characteristics in patients presenting with an acute vestibular syndrome to inform process improvement strategies for stroke code activation. We developed an ED triage diagnostic algorithm termed, “Dizzy-7”, based on evidence incorporating key history and physical examination elements derived in patients with acute posterior circulation ischemia. Subsequent analyses were performed on algorithmic utilization and its ability to predict stroke. Results: 1599 patients presented with acute dizziness over a 4-month period (2022-2023). Stroke code activation occurred in nearly one in four (366/1599) these presentations. 20% (319/1599) were ultimately diagnosed with stroke and of these, 49% (319/366) were identified following stroke code activation. The Dizzy-7 algorithm was used infrequently (4%) among all acute dizziness presentations. Of the 65 cases that incorporated the algorithm, 16 resultant stroke code activations occurred with 1 confirmed diagnosis (6%). We analyzed stroke alert cancellation and found an increased frequency in cancellation for those without use of the protocol at 22% (77/350) compared to those who did use it at 6% (1/16). Discussion: Accurate and reliable identification of acute ischemic stroke among patients presenting with acute dizziness remains complex. Implementation of a triage diagnostic algorithm based on contemporary evidence was infrequently implemented. Process improvement efforts targeted at greater algorithmic use, interprofessional collaboration, and education may improve stroke code utilization efficiency. Although based on limited sample size, a trend towards reduced stroke code cancellation rates were seen throughout the pilot Dizzy-7 algorithm use.

Vestibular function is associated with immune inflammatory response.

Association between vestibular function and immune inflammatory response has garnered increasing interest. Immune responses can lead to anatomical or functional alterations of the vestibular system, and inflammatory reactions may impair hearing and balance. Vestibular disorders comprise a variety of conditions, such as vestibular neuritis, benign paroxysmal positional vertigo, Meniere's disease, vestibular migraine, posterior circulation ischemia, and bilateral vestibular disease. Moreover, some patients with autoimmune diseases develop vestibulocochlear symptom. This paper offers an overview of prevalent vestibular diseases and discusses associations between vestibular dysfunction and immune diseases.

Occipital Steal Syndrome with Carotid Artery Occlusion–A Physiologic Study with Transcranial Doppler

Occipital or posterior steal syndrome is a constellation of signs and symptoms that arise from abnormal shunting of blood flow from the posterior cerebral circulation into its anterior counterpart leading to transient episodes of neurological deficits due to posterior circulation ischemia. A 45-year-old woman who experienced transient visual phenomena during breath holding was evaluated by transcranial Doppler sonography (TCD) for changes in cerebral blood flow. TCD revealed that the anterior cerebral vascular system was shunting blood away from its posterior counterpart in the setting of hypercapnia, resulting in visual symptoms. Using permissive blood pressure control, the steal phenomenon was resolved.

Bow Hunter Syndrome Involving Rare PICA Variant (P3-5.032)

<h3>Objective:</h3> NA <h3>Background:</h3> Rotational vertebrobasilar insufficiency, also known as bow hunter’s syndrome (BHS), is a rare cause of dynamic vertebral artery stenosis or occlusion during rotation of the head resulting in posterior circulation ischemia. It is potentially a reversible condition which can remain undetected and cause multiple ischemic strokes in the posterior fossa leading to significant disabilities. A 78-year-old male presented with a two-year history of transient episodes of dysarthria, vertigo, and gait disturbance lasting several minutes. These symptoms occurred after exercise or upon turning his head to the left. Dynamic transcranial doppler (TCD) revealed a significant decline in PCA flow velocities with leftward head turn followed by a hyperemic response after moving his head to a neutral position. Dynamic cerebral angiogram showed the presence of a congenitally anomalous origin of the right posterior inferior cerebellar artery (PICA) which originated at the level of C1 transverse foramen and extended under the C1 lamina. Upon neck rotation, there was near occlusion of the vertebral artery at the PICA origin. Hemilaminectomy of C1 was performed with near resolution of the patient’s symptoms. A follow up TCD confirmed improvement in blood flow parameters post-operatively. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> This case report describes a rare presentation of BHS involving an anomalous cervical origin of right PICA. The patient underwent multiple diagnostic studies including MRIs, inner ear physiology tests, and EEGs without any formal diagnosis. The TCD provided an effective and noninvasive diagnostic modality for position related transient neurological symptoms. Frequent use of such test can help diagnose patients with BHS and improve their quality of life. <b>Disclosure:</b> Miss Trujillo has nothing to disclose. Miss Otero-Bell has nothing to disclose. Dr. Girotra has nothing to disclose.

Operative V2 decompression for traumatic vertebrobasilar insufficiency: illustrative case.

Blunt vertebral artery injuries after cervical trauma due to the close anatomical relationship of the vertebral artery to the cervical spine may have fatal consequences because of posterior circulation ischemia and vertebrobasilar insufficiency. While the standard of care remains medical treatment by anticoagulation or antiplatelet therapy, surgical decompression of the vertebral artery is rarely indicated. The authors present a case of selective decompression of a traumatically constricted vertebral artery within the transverse foramen of C2 presenting with vertebrobasilar insufficiency due to bilateral aplasia of the posterior communicating arteries and contralateral hypoplasia of the vertebral artery. Because of their close relationship to the cervical spine, the vertebral arteries are at risk for blunt injury, which may present asymptomatically or with symptoms of posterior circulation ischemia or vertebrobasilar insufficiency either immediately or after a latency phase. The anatomical variability of (1) the vertebral arteries, (2) collateral brainstem perfusion, and (3) the individual injury pattern demands individualized treatment strategies. If endovascular treatment of hemodynamically relevant stenosis of the V2 segment of the vertebral artery poses too high a risk for vessel injury, decompression of the transverse foramen can be performed safely and without risk to the biomechanical stability of the cervical spine.

Clinical Analysis of Embryonic Posterior Cerebral Artery

Objective: To understand the clinical characteristics of patients with embryonic posterior cerebral artery and its correlation with abnormal vascular development. Methods: The clinical data of 396 patients with embryonic posterior cerebral artery confirmed by magnetic resonance angiography (MRA) and computed tomography angiography (CTA) were analyzed. Results: Two-hundred patients had clinical manifestations of posterior circulation ischemia, including recurrent dizziness, vertigo, and tinnitus; 45 had headaches, 97 had limb weakness, and 16 patients had syncope or impaired consciousness. Seventy-six patients with circulatory infarction were admitted to the hospital. There were 251 patients with history of hypertension, 74 with diabetes, 113 with hyperlipidemia, 13 with dominant vertebral artery, 10 with intracranial aneurysm, and 19 with absence of A1 segment of the anterior cerebral artery (considering developmental variation). Conclusion: Embryonic posterior cerebral artery develops abnormally during the embryonic period, often accompanied by abnormal vascular access. Due to abnormal hemodynamics, the incidence of posterior circulation ischemia, aneurysm, and infarction increases in such patients.

Effective Mechanical Thrombectomy for Posterior Circulation Ischemia Using Magnetic Resonance Imaging-based Arterial Structures.

To improve the success of mechanical thrombectomy, three-dimensional turbo spin-echo (3D-TSE) sequences on T2WI can be employed to estimate the vascular structure of the posterior circulation. In addition to the short imaging time of 3D-TSE T2WI (33 sec), it can visualize the outer diameter of the main cerebral artery, including the occluded vessels. However, to date, the efficacy of mechanical thrombectomy in the posterior circulation remains unclear, and safer and more efficient mechanical thrombectomy procedures are required. Assessment of the anatomical variations in the posterior circulation using 3D-TSE T2WI is valuable for access decisions, device selection, and safe device guidance and retrieval techniques to the target vessel. Herein, we present representative cases of basilar artery and posterior cerebral artery occlusions in our institute and describe the utility of preoperative 3D-TSE T2WI in these patients.

Impairment of attention network function in posterior circulation ischemia-evidence from the Attention Network Test.

This study aimed to investigate the effect of posterior circulation ischemia (PCI) on attention network function and to determine whether PCI is holistic or selective attention network deficit and which attention network is affected. Thirty-six PCI patients aged 30 to 75 were assessed using the Attention Network Test and the Mini-Mental State Examination (MMSE). There were no significant differences in age, sex, and education between PCI group and the control group (n = 32). All data were statistically analyzed by SPSS 23.0 software. There were no significant difference in the MMSE scores between the two groups. Compared with the control group, the PCI group had significantly shorter response time for alerting and orienting network. The executive control network response time was significantly longer in PCI group than in the control group. The overall mean response time was also significantly longer in PCI group than in normal control group. There was no significant difference in mean accuracy between the two groups. The alerting, orienting, and executive control networks were significantly less efficient in PCI group than in the control group (P < 0.01). This indicates impaired attention network in PCI patients. Since transient nerve seizures caused by vertebrobasilar ischemia may precede posterior circulation stroke, early assessment of cognitive function in patients with PCI is particularly important, and ANT is an excellent tool for this assessment.

SPAN2 SCALE: A NEW PREDICTIVE SCALE OF DISABILITY IN MINOR STROKE WITHOUT LARGE-VESSEL OCCLUSION

Background: Currently there is no predictive model in acute minor stroke without large vessel occlusion. Aims: Our objective was to evaluate the independent predictors that correlate with unfavourable outcome and to develop a predictive scale in acute setting. Methods: Retrospective analysis of consecutive acute minor stroke (NIHSS &lt;5) admitted within 4.5 hours to clinical onset who were previously not disabled and without large vessel occlusion on CT angiography (intracranial or extracranial occlusion or stenosis ≥50%). Unfavourable outcome was defined as modified Rankin Scale 3-6 at 90 days. Independent predictors of disability were included in the model. Results: A total of 408 patients with acute minor stroke (NIHSS &lt;5) were analyzed. Large vessel occlusion was detected in 83 (20%), who were excluded. The final analysis included 325 patients, with mean age of 68± 14 years, 59% were men and 14.5% had unfavourable outcome. On multivariate analysis, age &gt;70 years, NIHSS &gt;2, recurrent event, posterior circulation ischemia and previous stroke were associated with unfavourable outcome. Recurrent event was excluded to the model because this variable is not available in acute setting. With the variables detected in the logistic regression, a predictive model was made (SPAN2 scale: previous Stroke, Posterior ischemia, Age &gt;70 or NIHSS &gt;2). The model correctly classified 84% of the patients with unfavourable outcome. A score &gt;2 points on the SPAN2 scale showed a sensitivity 95%, specificity 51%, PPV 25% and NPV 99% of unfavourable outcome at 90 days. Conclusions: SPAN2 scale could be useful to stratify the risk of unfavourable outcome in acute phase of minor stroke without large vessel occlusion. Future studies may validate its usefulness in the selection of patients for thrombolytic therapy.

Microsurgical revascularization of a symptomatic proximal vertebral artery: pilot experiences from a single center.

Vertebral artery stenosis and occlusion (VASO) is a high-risk factor for posterior circulation stroke. Post-stent restenosis and drug tolerance have facilitated the exploration of microsurgical vascular reconstruction. This study aims to evaluate the safety and efficacy of microsurgical reconstruction of the proximal VA. Twenty-nine patients (25 men, aged 63.2 years) who had symptoms of posterior circulation ischemia underwent microsurgical revascularization for proximal VASO were retrospectively included in this study. Procedural complications and clinical and angiographic outcomes were reviewed. Twelve, three, and five patients underwent VA endarterectomy, artery transposition, or both, respectively; seven patients underwent vertebral endarterectomy plus stent implantation; and two patients failed surgery because of the difficult exposure of the VA and the occurrence of vascular dissection. The perioperative period-related complications included seven cases of Horner's syndrome, five cases of hoarseness, and one case of chylothorax. No cases of perioperative stroke or death were reported. The mean follow-up period was 28.4 (8-62 months). Most patients improved clinically; however, the vertebrobasilar ischemia symptoms did not decrease significantly in two patients during the follow-up. Moreover, follow-up imaging was performed in all the patients, and no signs of anastomotic stenosis were reported. Microsurgical reconstruction is an alternative option that can effectively treat refractory proximal VASO disease and in-stent stenosis, with a high rate of postoperative vascular recirculation. Prospective cohort studies with larger sample sizes must be conducted to validate the above conclusions.

Clinical characteristics, endovascular choices, and surgical outcomes of intracranial vertebral artery dissecting aneurysms: a consecutive series of 196 patients.

The authors aimed to evaluate the clinical features, endovascular strategy selection, and outcomes of vertebral artery (VA) dissecting aneurysms (VADAs) near the origin of the posterior inferior cerebellar artery (PICA). Clinical data were obtained from 196 patients with 202 VADAs who had been surgically treated at the authors' hospital between 2005 and 2021. The patients' medical records, imaging data, and follow-up outcomes were retrospectively analyzed. All 196 patients (148 male, 48 female; mean age 53 years) underwent endovascular therapy for VADA. The most common chief complaints were headache (56.6%), dizziness (40.8%), and other occasional symptoms (18.4%). Twenty-six patients experienced posterior circulation ischemia, and 25 patients experienced subarachnoid hemorrhage (SAH). On DSA images, 37 aneurysms were found in the dominant VA, and 165 aneurysms were found on the nondominant side. Eighty-eight VADAs had stenosis. Regarding the VADA location, there were 59 distal, 51 proximal, 23 ventral, 64 PICA, and 5 obliteration types. Single-stent implantation (10.9%), overlapping stent implantation (23.8%), flow diverter (FD) implantation (11.9%), single stent-assisted coil (SAC) embolization (31.7%), overlapping SAC embolization (12.9%), parent artery occlusion (PAO) (8.4%), and FD-assisted coil embolization (0.5%) were chosen. The follow-up rate was 82.7%. The modified Rankin Scale (mRS) score was 0.5 ± 1.1. Ninety-six patients underwent DSA. The complete occlusion rates were 100%, 81.4%, 56.7%, and 76.5% in the PAO group, SAC reconstruction group, stent implantation group, and FD implantation group, respectively. Young patients showed a higher probability of SAH, and elderly patients showed a higher probability of posterior circulation infarction. The surgical plan selection should be based on the SAH history, VA dominant side, and PICA origin location.

Limb-shaking transient ischemic attack in posterior circulation ischemia: a case report

Limb-shaking transient ischemic attack (LS-TIA) is a rare clinical manifestation of steno-occlusive carotid lesions. Reports of LS-TIA caused by posterior circulation ischemia are rare. Here, the case of a 56-year-old male patient with a history of epilepsy, who presented with dizziness, nausea and vomiting, is reported. Initial brain magnetic resonance imaging (MRI) indicated no signs of acute ischemia, and the patient's symptoms had not relieved despite drug administration to treat dizziness. During a vestibular function test on the next day, he developed sudden left-limb shaking without disturbance of consciousness or facial twitching. Considering a seizure, an anti-epileptic drug was administered, but no improvement was observed. Eight hours later, the patient experienced left-limb paralysis, and re-examination of the MRI indicated brainstem infarction. The patient recovered well with antiplatelet and antiatherosclerotic therapy. While LS-TIA is a rare manifestation of TIA of the carotid arterial system, posterior circulation ischemia may also manifest as LS-TIA. If a patient presents with limb shaking due to postural changes despite a history of epilepsy, LS-TIA should be highly suspected.

Detection of Neonicotinoid Insecticides and Their Metabolites in Human Cerebrospinal Fluid.

Detection of Neonicotinoid Insecticides and Their Metabolites in Human Cerebrospinal Fluid.

Posterior circulation stroke diagnosis in unselected group of acutely dizzy patients

BackgroundsDiagnostics of a posterior circulation ischemia (POCI) in patients with acute vertigo is a challenging task. Recently, the combination of HINTS (Head Impulse, Nystagmus and Test of Skew) exam and ABCD2 has been recommended to identify stroke in these patients. Until now, studies regarding HINTS have mostly been tested on preselected patient groups and their results are only partially applicable to real clinical practice. AimsTo compare the sensitivity and specificity of HINTS and ABCD2 and their combination in unselected acutely dizzy patients in the emergency department (ED) toward posterior circulation stroke detection. MethodsA prospective cross-sectional monocentric study in ED patients with acute onset of dizziness lasting less than 72 h. Their clinical characteristics, HINTS, vascular risk factors, ABCD2 scores and neuroimaging data were analyzed. Results140 patients were recruited. Acute stroke was identified by MRI in 39 patients. All patients had central pattern nystagmus, skew deviation or further focal neurological finding. The age (≥60) and arterial hypertension clearly distinguished stroke and non-stroke group (p < 0001). The sensitivity of HINTS, ABCD2 and their combination in the unselected group was high (82,1 - 97,4%), but specificity low. After removing patients with inconclusive diagnosis, including transitory ischemic attack, specificity was much higher and comparable to previously published results. ConclusionsThe sensitivity and specificity of HINTS in previously published studies may vary because of their selection criteria. Even though, our study was performed on the unselected patient cohort, combination of HINTS and ABCD2 remained highly sensitive in detecting POCI and outperformed each of these tests alone.