Posterior Circulation Stroke Research Articles

Abstract TP132: Optimal CT Perfusion Post-Processing Method in Posterior Circulation Stroke

Objective: CT-perfusion (CTP) has revolutionised stroke care by improving diagnostic accuracy and expanding eligibility to acute therapies. Software packages utilise various mathematical techniques to transform raw perfusion data into measures of infarct core and ischaemic penumbra. These techniques have been derived from studies of anterior-circulation stroke and not yet validated in posterior circulation stroke (PCS). We examined the optimal CTP thresholds for acute PCS. Methods: Data were analysed from 331-patients diagnosed with a PCS enrolled in the International-stroke-perfusion-registry (INSPIRE). Twenty-seven-patients with baseline multimodal-CT with occlusion of a large posterior-circulation (PC) artery and follow up diffusion-weighted-MRI at 24-48 hours were included. CTP parametric maps were generated using five different post-processing methods. Receiver-operating-curve analysis was used to determine the optimal perfusion parameter and thresholds. Results: Partial deconvolution was the optimal post-processing method for characterisation of ischaemic penumbra and infarct core. Mean transit time (MTT) at a threshold of >165% and >195% most accurately defined ischaemic core (AUC=0.73) and penumbra (AUC=0.78) respectively. Post-processing technique influenced accuracy of core (AUC range=0.54-0.73) and penumbra (AUC range=0.72-0.79) estimates. MTT was consistently the most accurate parameter at distinguishing core and penumbra across all post-processing methods. Conclusion: CTP has significant diagnostic utility in PCS. Accuracy of CTP varies considerably by post-processing method. The underlying post-processing technique employed by individual software packages should be considered when interpreting the accuracy of ischemic core and penumbra estimates.

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 TP53: Above Par on the Back Nine: Improving Triage of Posterior Circulation Stroke

Background and Purpose: Notoriously difficult to recognize, posterior circulation strokes (PCS) can be some of the most devastating. It is incumbent on the triage nurse to recognize these signs and symptoms. This project was developed to educate frontline ED staff on early identification of posterior strokes, decrease time to recognition, and improve outcomes. Methods: The community Primary Stroke Center (PSC) identified the need to improve recognition of PCS after a series of treatment-eligible patients were missed. A team was created including the directors of the PSC and associated Comprehensive Stroke Center (CSC), emergency room physicians, and nurses. A triage algorithm was created to capture as many strokes as possible without a glut of false positives. This included focal and non-focal signs of stroke. ANY sign of stroke should initiate the code stroke (CS) process provided that the presentation was within 24 hours of last known well, the presentation was sudden, and the symptoms were disabling to the patient. Once approved, the algorithm and education were provided to all patient-facing ED staff. Updates were added to huddle notes and a copy of the algorithm was made available at all triage areas. Data was collected retroactively for a total of 16 months, 8 months prior to the intervention and 8 months after. Results: - For all PCS the median time from arrival to initiation of CS improved from 9 minutes to 1 minute - For all PCS the median time from arrival to confirmation of stroke improved from 597 minutes to 249 minutes - Prior to intervention, only 60% of CS-eligible patients had a CS initiated, compared to 92% after - Ninety-day Rankin was from 0-2 in 86% of PCS patients prior to intervention compared to 100% after Conclusions: A clear triage process can maximize identification of PCS, increase capture of treatment-eligible patients, and decrease disability. A PSC with tele-stroke coverage and ongoing education improved identification of posterior circulation strokes and outcomes. Key takeaways for success include clear and concise code stroke algorithm, support from providers, and ongoing educational interventions. While this data is preliminary, we will continue to track and trend. Next steps should include education directed to EMS personnel in the field.

Traumatic vertebral artery injury: Denver grade, bilaterality, and stroke risk. A systematic review and meta-analysis.

Vertebral artery injury (VAI), a complication of blunt trauma, may cause posterior circulation stroke. An association of disease severity, classified in Denver grades, with stroke risk has not been shown. Using a literature-based analysis, the authors estimated the incidence of VAI following blunt trauma with the aim to investigate the impact of Denver grade and bilateral VAI on stroke occurrence. A systematic review of the literature on VAI following blunt trauma was conducted, and data on its incidence, the severity per Denver grade, and stroke occurrence were collected. The incidence of VAI and stroke occurrence were analyzed cumulatively and between Denver grades. A meta-analysis with random-effects models was performed. Fifty-six studies including 2563 patients were identified. The overall incidence of VAI was 0.49% among blunt trauma cases and 14.5% among patients screened via any type of angiography. The incidence rates of bilateral VAI and concurrent carotid injury among all VAIs were 12.3% and 19.2%, respectively. VAI severity by Denver grade was as follows: grade I, 23.4%; grade II, 28.2%; grade III, 5.8%; grade IV, 42.1%; and grade V, 0.5%. The overall stroke risk was 5.32%, differing significantly among lesions of different Denver grades (p = 0.02). Grade III and IV lesions had the highest stroke prevalence (9.8% and 10.9% respectively), while strokes occurred significantly less frequently in patients with grade I and II lesions (1.9% and 3.0%, respectively). Denver grade V cases were too rare for meaningful analysis. Bilateral VAI was associated with a 33.2% stroke prevalence. The association between Denver grade and stroke occurrence persisted in a sensitivity subanalysis including only unilateral cases (p = 0.03). VAI complicates a small yet nontrivial fraction of blunt trauma cases, with Denver grade IV lesions being the most common. This is the first study to document a significantly higher stroke prevalence among grade III and IV VAIs compared with grade I and II VAIs independently from bilaterality. Bilateral VAIs carry a significantly higher stroke rate.

Abstract WP154: Factors Associated With Prolonged Length of Intensive Unit Stay Following Mechanical Thrombectomy for Acute Ischemic Stroke

Objective and Background: The objective of the study was to investigate factors affecting the length of stay (LOS) in the intensive care unit (ICU) following mechanical thrombectomy (MT) for acute ischemic stroke. Methods: We identified patients undergoing MT from a prospective registry at a comprehensive stroke center between January 2021 and June 2023. ICU stay for more than 48 hours was defined as prolonged ICU stay. Results: Out of 363 patients, 41.6% (n=151) required a prolonged ICU stay. Prolonged ICU stay were more likely to have higher baseline median NIHSS score (19 vs. 14%, p < 0.0001), posterior circulation stroke (12.6% vs. 5.7%, p = 0.0200), intubation for the procedure (86.7% vs. 69.3%, p = 0.0001), complications including pneumonia (18.5% vs. 6.1%, p = 0.0002), deep vein thrombosis (7.3 vs. 2.3, p = 0.0242), urinary tract infection (12.6% vs. 6.1%, p = 0.0326), and symptomatic intracerebral hemorrhage (7.3% vs. 1.9%, p = 0.0109). Patients receiving thrombolysis prior to thrombectomy were less likely to have a prolonged LOS (27.8% vs. 41.7%, p = 0.0086). Independent predictors for prolonged ICU LOC included higher NIHSS (odds ratio [OR] 2.7, p = 0.0002), intubation prior to the procedure (OR 2.7, p = 0.0002), not receiving IV thrombolysis (OR 2.3, p = 0.0069), thrombolysis in cerebral infarction (TICI) score ≥ 2B (OR 0.458, p = 0.0754), composite ICU complications (OR 2.4, p = 0.0027), and symptomatic intracranial hemorrhage (OR 5.2, p = 0.0157). Conclusions: Almost one-third of the acute ischemic stroke patients required a prolonged ICU stay following MT. A better understanding of the factors associated with prolonged ICU stay may assist in appropriate allocation of resources.

Abstract TMP70: Association of Distal Hyperintense Vessel Sign and Outcomes in Patients With Symptomatic Posterior Circulation Intracranial Atherosclerotic Disease

Objectives: The Distal Hyperintense Vessel (DHV) sign on FLAIR imaging is a radiographic marker of inadequate blood flow due to poor collateral flow distal to the stenotic artery. Previous studies suggest that the DHV sign was associated with early recurrent ischemic stroke in the anterior circulation secondary to intracranial atherosclerotic disease (ICAD). However, its significance in ischemic stroke in the posterior circulation is unknown. Here, we investigate the association of DHV sign in the basilar artery and outcomes at discharge in patients with posterior circulation stroke or TIA secondary to ICAD. Methods: We retrospectively reviewed patients with ischemic strokes or TIA attributed to ICAD of the basilar or vertebral arteries admitted to two comprehensive stroke centers affiliated with UTSW Medical Center from 2010 to 2022. Patients were included if they met VERiTAS criteria (≥50% vertebrobasilar stenosis). The DHV sign was defined as positive when the increased intensity in the basilar artery distal to stenosis was higher than the surrounding CSF signal. The DHV sign was evaluated by blinded vascular neurologists and neuro-radiologists. The primary outcome was mRS at discharge. The secondary outcome was the incidence of clinical deterioration during admission, defined as any worsened neurological exam with associated new infarct or infarct expansion in the posterior circulation. Results: A total of 135 patients were included in the study. A total of 33 (24%) patients had the presence of the DHV sign on admission MRI. Compared to patients without DHV sign, patients with DHV sign had higher NIHSS scores on admission (median 7 vs 2, p<0.001), higher risk of clinical deterioration during hospitalization (27% vs 2%, p<0.001), higher mRS scores at discharge (median 3.45 vs 1.8, p<0.001) and higher mortality rate (24% vs 0%, p<0.001). In multivariate analysis, the DHV sign was an independent predictor of higher mRS scores at discharge. Conclusions: In patients with ischemic stroke or TIA secondary to basilar or vertebral artery atherosclerotic stenosis, the presence of the DHV sign in the basilar artery is associated with more severe disease and poorer outcomes at discharge compared to patients without DHV sign.

The association between vertebral artery hypoplasia and fetal-type variants of the posterior cerebral artery with imaging findings among patients with posterior circulation stroke: A single-center cross-sectional study.

The present study investigated the correlation between vertebral artery hypoplasia and fetal-type variations of posterior cerebral arteries with stroke patterns and imaging findings in individuals with posterior circulation ischemic stroke. In this cross-sectional study, patients with symptoms of acute ischemic stroke in the posterior circulation system referred to Ghaem Hospital in Mashhad between 2016 and 2022 were investigated. Demographic data, including age, gender, systemic diseases, history of previous stroke or transient ischemic attacks, and clinical manifestations of patients, were recorded using questionnaires and checklists from patient files. The results of imaging studies, including magnetic resonance imaging and computed tomography angiography, were also recorded. The obtained data were analyzed by SPSS statistical software. Among 974 patients suffering from posterior circulation ischemic stroke, 155 patients with an average age of 60.44 ± 13.95 years were included in the study, out of which 97 patients (62.6%) were male. Unilateral vertebral artery hypoplasia on the right, left, and bilateral hypoplasia was present in 67 (43.2%), 35 (22.6%), and 5 (3.2%) patients, respectively. There were complete unilateral fetal origin on the right in 38 (24.5%), complete unilateral on the left in 12 (7.7%), partial unilateral on the right in 12 (7.7%), partial unilateral on the left in 6 (3.9%), complete bilateral in 14 (9%), and partial bilateral in 8 (5.2%) patients. There was no significant relationship between vertebral artery hypoplasia and PCA fetal-type variants with different ischemia locations and infarct patterns (p > 0.05). Also, there was no significant relationship between the age and gender of patients with ischemia location and infarct pattern (p > 0.05). Despite previous evidence showing a relation between vertebral artery hypoplasia and PCA fetal-type variants as risk factors for PC stroke, the present study did not establish a significant correlation between these factors and the location of ischemia and infarct patterns.

Abstract WP30: Therapeutic Hypothermia With Thin Liquid Convection is Safe and Feasible in Acute Stroke Patients: The Helping Stroke Patients With ThermoSuit Cooling (SISCO) Pilot Study

Introduction: Animal studies have shown that therapeutic hypothermia of 32-34°C (TH) leads to a drop in infarct size after cerebral artery occlusion. Data suggests that early, rapid TH must be achieved to maximize neuroprotection from ischemic injury. There have been two RCTs of TH in stroke patients, both of which cooled slowly and failed to show the benefit of TH. Objective: The present study assessed the safety and feasibility of the ThermoSuit System (TSS) to induce rapid TH in acute ischemic stroke patients enrolled in the SISCO pivotal phase I trial. The TSS circulates cold water directly over the patient’s skin to achieve TH and has previously demonstrated significantly faster cooling than other methods. Methods: Eligible stroke patients were enrolled with an NIHSS > 5, less than 8 hours from LKW, or who met the extended window thrombectomy criteria. Patients were sedated and intubated according to protocols. Cooling was initiated by circulating ice-cold water (0-8°C) through the TSS. The patients were cooled until the core temperature reached 34-33°C, and the suit was removed. Temperature was maintained at 32°C to 34°C for 24 hours following the cooling induction using a conventional cooling blanket. Criteria for study success were defined as 1) at least 50% of the patients achieving 32-34°C within 1 hour; 2) NIHSS and mRS scores at 90 days post-stroke were not statistically worse than historical controls; 3) no significant increase in adverse event rates in cooled subjects vs. historical controls. RESULTS 14 subjects were enrolled, and 13 were cooled. 2 patients were excluded due to treatment delays and 1 due to missing outcome data, leaving 10 patients available for complete analysis. The average NIHSS on admission was 18, and the average patient age was 65. 7 patients had an LVO in the anterior circulation and 3 had posterior circulation strokes. All study success criteria were met. The median cooling time to 34°C was 40 minutes. The rates of unacceptable outcomes at 90 days (mRS >3) were 45% in 1314 published historical controls but only 10% in cooled subjects. Conclusion: The TSS is a safe and effective tool for rapid TH in ischemic stroke patients. Further studies are warranted to assess whether this cooling method is neuroprotective for these patients.

Abstract 75: Validation of Vascular Location Subcodes for Acute Ischemic Stroke by the International Classification of Diseases-10

Background: The affected vascular region is included in the International Classification of Diseases-10 (ICD-10) coding scheme for stroke. These data have the potential to enable studies of vascular and regional location. For example, differentiating anterior versus posterior circulation stroke. However, the coding in real world practice has not been validated. The purpose of this study was to evaluate the validity of these subcodes. Methods: We identified all hospitalizations for ischemic stroke at a single center from 2018-2022. We selected a random sample of 100 hospitalizations with vascular region subcoding specifying 50 with anterior circulation subcodes (carotid, anterior cerebral artery [CA], middle CA) and 50 with posterior circulation subcodes (vertebral, basilar, cerebellar, posterior CA). The gold standard classification for the primary infarct vascular distribution was made by the study team, blinded to the subcode, after review of the available imaging studies and the medical record. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the administrative data posterior circulation subcodes versus anterior circulation subcodes with the gold standard classification. We also calculated the kappa statistic for overall agreement of the 7 vascular regions. Results: The final study population was 50 ICD-10 anterior circulation ischemic stroke hospitalizations and 50 ICD-10 posterior circulation ischemic stroke hospitalizations. Mean age was 68 (SD, 15) and 44% (44/100) were female. Mean NIHSS was 8 (SD, 8). Neuroimaging was performed in 100% (100/100): Head CT, 95% (95/100); MRI brain, 77% (77/100). The accuracy of the ICD-10 classification for primary posterior circulation stroke was as follows: sensitivity 89% (49/55); specificity 98% (44/45); PPV 98% (49/50); NPV 88% (44/50), respectively. The reliability of the 7-region classification was excellent (kappa statistic, 0.85). Conclusions: We found that the ICD-10 subcode classification for vascular location used in clinical practice had excellent agreement with our gold standard based on medical review. These data validate the use of these subcodes for anterior versus posterior circulation stroke studies.

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.

Validation of Vascular Location Subcodes for Acute Ischemic Stroke by the International Classification of Diseases-10

BackgroundVascular region of infarct is part of the International Classification of Diseases-10 (ICD-10) coding scheme for ischemic stroke. These data could potentially be used for studies about vascular location, such as comparisons of anterior versus posterior circulation stroke. The objective of this study was to evaluate the validity of these subcodes. MethodsWe selected a random sample of 100 hospitalizations specifying 50 with anterior circulation ICD-10 ischemic stroke (carotid, anterior cerebral artery [CA], middle CA) and 50 with posterior circulation stroke (vertebral, basilar, cerebellar, posterior CA). The gold standard primary vascular distribution was scored using imaging studies and reports, blinded to the subcode. We compared gold-standard distribution to coded distribution and calculated the operating characteristics of ICD-10 posterior circulation versus anterior circulation codes with the gold standard. We also calculated the kappa statistic for agreement across all 7 vascular regions. ResultsIn our population of 100 strokes, mean NIHSS was 8 (SD, 8). Head CT was performed in 95 % (95/100) and MRI in 77 % (77/100). The gold standard classified 55 primary posterior circulation strokes (26 PCA, 16 cerebellar, 8 basilar, 5 vertebral), 44 primary anterior circulation strokes (35 MCA, 6 carotid, 3 ACA), and 1 stroke with no infarct on imaging. The accuracy of the ICD-10 classification for primary posterior circulation stroke versus anterior circulation/no infarct was: sensitivity 89 % (49/55); specificity 98 % (44/45); positive predictive value 98 % (49/50); negative predictive value 88 % (44/50). The reliability of the 7-region classification was excellent (kappa 0.85). ConclusionsWe found that ICD-10 classification of vascular location in routine practice correlates strongly with gold-standard localization for hospitalized ischemic stroke and supports validity in differentiating posterior versus anterior circulation. At a more granular vascular level, the location reliability was excellent, although limited data were available for some subcodes.

Posterior circulation lesions are more frequently associated with early seizures after a stroke

Background. Early seizures (ES) following stroke are prevalent among the elderly population, representing the most common type of acquired seizures. This study aimed to determine the incidence of ES and investigate potential associations with various clinical and radiological factors. Materials and Methods. 260 stroke patients (mean age 72±13.2, 48.5% females) were prospectively enrolled and followed. Baseline demographic data, clinical data, stroke subtype, ES occurrence, National Institutes of Health Stroke Scale (NIHSS) scores, and Alberta Stroke Program Early CT Score (ASPECT) were collected and analyzed. Results. ES was observed in 11.6% of patients with ischemic stroke compared to 7.1% among patients with hemorrhagic stroke. ES occurred more frequently in those with posterior circulation stroke (18.5% vs. 7.1%, P=0.008) and those with NIHSS >15 (19.4% vs. 8.4%, P=0.04). In a logistic regression analysis that adjusted for vascular risk factors and NIHSS, posterior circulation stroke remained significantly associated with ES, with an odds ratio of 3.14 (95% CI 1.20 to 7.73, P=0.012). Conclusions. This study revealed that ES following stroke is more common in patients with posterior circulation lesions. These findings emphasize the need for further investigation into additional factors that may influence ES occurrence and its impact on stroke management and patient outcomes.

Sex differences in outcomes after endovascular treatment in posterior circulation stroke: results from the MR CLEAN Registry

BackgroundWomen with anterior circulation large vessel occlusion (LVO) have been reported to have worse outcomes after endovascular treatment (EVT) than men. Whether these disparities also exist in LVO of the...

Acoustic evoked potentials characteristics in patients with vertebral artery hypoplasia and posterior circulation stroke

Background/Aim. Acoustic evoked potentials (AEPs) represent an electrophysiological method used in diagnosing pathological changes of the brain stem (BSt), the acoustic nerve (its peripheral and central part), in patients in coma, in the confirmation of cerebral death, etc. The response includes seven negative waves which are generated in the structures of the BSt vascularized by the arteries of the posterior circulation. However, in everyday practice, due to their constancy, the first five waves are followed. The vertebral artery hypoplasia (VAH) is assumed to affect the AEPs finding. The current definition of VAH includes the criterion that the diameter of the blood vessel is ? 2 mm and that the ratio of the diameter of the left and right vertebral artery is ? 1 : 1.7. VAH is found in 5.3% of cases of the total population and its presence increases the risk of posterior circulation stroke (PCS). The aim of this study was to show a higher frequency of pathological findings of AEPs in patients with VAH and PCS and demonstrate the characteristics of AEP in that group of patients. Methods. This prospective study included 163 patients diagnosed with PCS over a period of two years. Computed tomography (CT) and magnetic resonance (MR) imaging (MRI) established the diagnosis of PCS. Suspicion of VAH was found by Color Doppler ultrasonography and confirmed by CT and MR angiography. All patients underwent AEPs testing. Wave amplitudes and interwave latencies (IWL) were monitored. Results. There was no statistically significant difference between gender (?2 = 1.823; p = 0.176) and age in relation to VAH (p = 0.815). A statistically significant greater number of patients with multiple PCS had a positive VAH finding (VAH group, 42.3%) compared to those without VAH (noVAH group, 26.6%) (?2=4.278; p=0.038). A statistically significant greater number of pathological AEPs was found in the group of patients with PCS and VAH (?2 = 4.899; p = 0.026). A statistically significant IWL change accompanied by low amplitude waves in the VAH group has been determined (?2 = 4.465; p = 0.034). Conclusion. The distribution of VAH is not gender- or age-related. The frequency of pathological AEPs findings (presence of associated changes in wave amplitudes and prolonged IWL) is statistically significantly higher in patients with VAH and PCS.

Posterior circulation stroke: Profile and functional outcome in patients attending Tanta stroke unit

Posterior circulation stroke: Profile and functional outcome in patients attending Tanta stroke unit

Acquired Cerebral Achromatopsia Secondary to Occipital Stroke

Background: Acquired cerebral achromatopsia, a form of color vision impairment, is infrequently reported and often results from injuries to the occipital cortex. Case Presentation: We detail a case of a middle-aged women with vascular risk factors who visited the emergency department with blurred vision and disturbances in color perception, characterized as an inability to differentiate colors. A notable finding in her neurological examination was homonymous hemianopia. Hyperacute magnetic resonance imaging revealed a subacute infarction in the right occipital lobe. As she was outside the treatment window for alteplase and invasive interventions, she received aspirin and clopidogrel as treatment. Discussion: Patients with posterior circulation strokes often present with non-specific symptoms, which can lead to delayed diagnoses and treatment. Acquired cerebral achromatopsia, the inability to perceive color after acute brain injury, is a rare phenomenon associated with PCA stroke that has not been well studied yet. It usually involves the ventral occipitotemporal cortex in V4 complex, which anatomically is theorized to be the brain's color center. A comparison was made between two instances of acquired cerebral achromatopsia. In the first case, a 60-year-old woman displayed hemi-achromatopsia in the right visual field. In the second case, a 74-year-old woman suffered two strokes. The first stroke on the left hemisphere resulted only in a right homonymous hemianopia with normal color perception; however, upon the occurrence of the second stroke on the right hemisphere, she developed full field achromatopsia. The contrasting presentations of these cases after lesions in the ventral posterior regions of their left hemisphere suggests a hypothesis that individual differences might exist in the hemispheric laterality of color centers in the brain. Our patient experienced a right subacute occipital stroke; however, she exhibited bilateral achromatopsia. The exact cause of this full field achromatopsia from this specific lesion remains uncertain, but her presentation might support the hypothesis. Conclusion: Posterior circulation stroke infarctions often present with nonspecific symptoms making timely diagnosis and management challenging. Achromatopsia is an infrequent and subtle manifestation of posterior circulation infarctions that warrant further investigations and management.

Successful revascularization therapy in altered mental state patient with posterior circulation stroke and left subclavian artery partial obstruction: a case report and review of literature

Background: This case report highlights the successful revascularization therapy and favorable functional outcome in a rare and challenging case involving basilar artery occlusion and left subclavian artery partial obstruction. Case Presentation: We report a patient presented with a high National Institutes of Health Stroke Scale score and altered mental state following collapse. Timely intervention, with multidisciplinary team approach including mechanical thrombectomy and intravenous thrombolysis, led to a remarkable neurological recovery. The discussion emphasizes the significance of prompt revascularization in cases of posterior circulation stroke and underscores the need for further research on multiple arterial obstructions. Conclusion: This case illustrates the potential for positive prognostic indicators even in complex scenarios, ultimately improving patient outcomes in such critical conditions.

Risk factors of acute kidney injury during hospitalization in acute ischaemic stroke patients undergoing mechanical thrombectomy.

Acute kidney injury (AKI) seems to worsen the prognosis of acute ischaemic stroke (AIS) patients treated with mechanical thrombectomy (MT). At the same time, the procedure of MT increases AKI risk by iodinated contrast use. Identification of factors predisposing to AKI after MT is important for recognizing vulnerable patients and successful prevention. To identify factors associated with the occurrence of AKI during hospitalization in MT-treated AIS patients. The study included all AIS patients treated with MT in the University Hospital in Krakow from 2019 to 2021. The diagnosis of AKI during hospitalisation was based on serum creatinine concentration levels, according to the Kidney Disease Improving Global Outcomes guidelines. We compared patients with and without AKI in terms of age, sex, comorbidities, stroke course and laboratory test results at admission. We identified factors associated with the occurrence of AKI using univariate logistic regression analysis, with significant variables subsequently added to the multivariate analyses. Among 593 MT-treated AIS patients the incidence of AKI during hospitalisation was 12.6%. AKI development was associated with diabetes, chronic kidney disease, total volume of iodinated contrast obtained during hospitalisation, posterior circulation stroke, lack of intravenous thrombolysis, and laboratory test results at admission: haemoglobin, glucose, urea, potassium, and creatinine. Total contrast volume and urea level were the most important independent risk factors associated with occurrence of AKI. AKI is common in MT-treated AIS patients. There is a need to establish a protocol for decreasing the risk of AKI in AIS patients undergoing MT and, in case it occurs, a procedure for its treatment.

Medical Management of Traumatic Vertebral Artery Injury Is Safe Regardless of the Severity of Injury

Management of traumatic vertebral artery injury (VAI) remains under debate. Current consensus reserves surgical or endovascular management for high-grade injury in order to prevent stroke. We sought to evaluate the factors that influence posterior fossa stroke outcomes following traumatic VAI. A search of the prospectively maintained PROOVIT trauma registry of patients older than 18years of age with a diagnosis of VAI was performed at a level 1 trauma center from 2013 to 2019. Patient demographics, type of injury, the timing of presentation, Biffl Classification of Cerebrovascular Injury Grade score, medical management, procedural interventions, and stroke outcomes were analyzed. VAIs were identified in 66 trauma patients were identified out of 14,323 patients entered into the PROOVIT registry. The dominant mechanism was blunt injury (91.5% vs. 8.5%, blunt versus penetrating). Nine patients presented with symptomatic ipsilateral posterior circulation strokes visible on imaging. The average Biffl classification grade was similar between the stroke and nonstroke groups (2.0 vs. 1.5; P=0.39). The average injury severity score (ISS) between stroke and nonstroke groups was also similar (9.0 vs. 14.0; P=0.35). All 9 patients in the stroke group had magnetic resonance imaging verification of their infarct within an average of 21.2hr from presentation. In the stroke group, 1 patient underwent diagnostic angiography but had no intervention. In the nonstroke group, all were treated with medical management alone and none underwent vertebral artery intervention. During a mean follow-up of 14.5months, no patients experienced a new neurological deficit. The severity of VAI by Biffl grading and ISS are not associated with ischemic stroke at presentation following VAI. Medical management of VAI appears safe regardless of Biffl and ISS staging in this trauma population. Neurological changes related to embolic stroke were generally appreciated on presentation. Conservative medical management was sufficient to protect from secondary neurological deficit regardless of index vertebral injury.

Case report: Acute audiovestibular presentation following hemi-pontine infarction

Posterior circulation stroke is an uncommon cause of sudden-onset sensorineural hearing loss (SSNHL). Anterior inferior cerebellar artery occlusion results in ipsilateral peripheral audiovestibular dysfunction. Few reports describe posterior circulation stroke presenting with contralateral SSNHL and acute vestibular and focal neurological signs. We present a case of contralateral SSNHL and isolated acute central vestibular dysfunction in the absence of other central focal neurological deficits. To the best of our knowledge, this has not been described to date. The patient was identified to have asymmetrical SSNHL, subtle skew deviation with left head tilt, and significant refixation saccades on video head impulse test despite bilaterally normal vestibulo-ocular reflex gains. Left pontine infarct was suspected and confirmed on magnetic resonance imaging. The patient was treated with an appropriate antiplatelet regimen. We highlight the importance of a thorough clinical diagnostic work-up as posterior circulation strokes with isolated audiovestibular deficits can be easily missed if other significant neurological deficits are absent.