From the Guidelines
Clinical Manifestations of Brainstem Stroke in Posterior Circulation Stroke
A brainstem stroke due to posterior circulation stroke can present with a variety of severe and potentially life-threatening symptoms. The clinical manifestations can include sudden onset of dysphagia, dysarthria, ataxia, vertigo, diplopia, and weakness or numbness of the face or extremities 1.
Key Symptoms and Signs
- Altered level of consciousness: Patients with posterior circulation strokes, especially those involving the brainstem, may present with an altered level of consciousness, necessitating aggressive airway management 1.
- Cranial nerve deficits: Deficits in cranial nerves such as the oculomotor (III), trochlear (IV), trigeminal (V), abducens (VI), facial (VII), vestibulocochlear (VIII), glossopharyngeal (IX), vagus (X), spinal accessory (XI), and hypoglossal (XII) nerves can occur, leading to symptoms like diplopia, facial weakness, and dysphagia.
- Motor and sensory deficits: Weakness or numbness of the face or extremities can be present, depending on the specific area of the brainstem affected.
Importance of Prompt Medical Attention
Given the potential for severe and rapidly evolving symptoms, immediate medical attention is crucial for patients suspected of having a brainstem stroke due to posterior circulation stroke. Prompt evaluation and management can significantly impact outcomes, including the potential for thrombolytic therapy if the patient presents within a suitable time frame and meets the necessary criteria 1.
Management Considerations
While the provided evidence does not directly address the management of brainstem strokes in posterior circulation strokes, general principles of acute ischemic stroke management apply, including:
- Thrombolytic therapy: Consideration for intravenous tissue plasminogen activator (tPA) if the patient presents within 4.5 hours of symptom onset and meets standard criteria.
- Blood pressure management: Careful control of blood pressure to ensure eligibility for tPA and minimize the risk of hemorrhagic transformation.
- Antiplatelet therapy: Initiation of antiplatelet therapy, such as aspirin, within 24-48 hours after stroke onset, if not contraindicated.
- Investigation of stroke cause: Evaluation for vascular risk factors and consideration of anticoagulation for cardioembolic sources or other conditions requiring anticoagulation.
From the Research
Clinical Manifestations of Brainstem Stroke in Posterior Circulation Stroke
The clinical manifestations of a brainstem stroke in a posterior circulation stroke can vary, but common symptoms include:
- Dizziness or vertigo 2, 3
- Dysarthria (slurred speech) 4, 3
- Diplopia (double vision) 4, 3
- Ataxia (loss of coordination) 3
- Truncal ataxia (loss of balance) 3
- Dysmetria (loss of coordination and balance) 3
- Isolated vertigo 4
- Non-focal symptoms such as nausea and vomiting 4
- Binocular visual disturbance 4
- Transient generalised weakness 4
Diagnostic Challenges
Diagnosing posterior circulation stroke can be challenging due to the non-specific symptoms and the limited sensitivity of imaging tests such as CT and CT angiography 2, 3. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful in identifying dizziness presentations concerning for stroke, but it should only be used in patients with continuous dizziness who have ongoing nystagmus 3.
Importance of Early Recognition
Early recognition and diagnosis of posterior circulation stroke are crucial to improve outcomes, as delayed treatment can lead to poor prognosis 5, 2, 6, 3. Emergency clinicians should consider posterior circulation stroke in patients with dizziness or vertigo, even in younger patients and those without traditional stroke risk factors 3.