From the Guidelines
Posterior circulation stroke typically presents with distinct symptoms including vertigo, ataxia, diplopia, visual field defects, and crossed sensory or motor deficits, making them challenging to diagnose. These symptoms occur due to the involvement of the vertebrobasilar arterial system, which supplies blood to the brainstem, cerebellum, and posterior portions of the cerebral hemispheres 1. The clinical manifestations of posterior circulation stroke can be variable, but common presentations include headache, neck pain, vertigo, nausea, visual disturbances, or syncope 1. It is crucial to promptly recognize these symptoms as posterior circulation strokes can rapidly progress to cause significant disability or death due to the critical structures supplied by the posterior circulation, including respiratory and cardiac control centers in the brainstem.
Some key points to consider in the clinical manifestations of posterior circulation stroke include:
- Vertigo and ataxia are common symptoms due to the involvement of the cerebellum and its connections 1
- Diplopia and visual field defects can occur due to the involvement of the brainstem and its cranial nerve nuclei 1
- Crossed sensory or motor deficits can occur due to the involvement of the brainstem and its descending tracts 1
- The symptoms of posterior circulation stroke can be subtle and may not always be immediately recognized, making a high index of suspicion necessary for diagnosis 1
In terms of diagnosis and management, it is essential to perform rapid neuroimaging with CT or MRI to confirm the diagnosis, followed by thrombolysis with intravenous alteplase if within 4.5 hours of symptom onset and no contraindications exist 1. Mechanical thrombectomy should be considered for eligible patients with large vessel occlusion presenting within 24 hours. Antiplatelet therapy with aspirin and secondary prevention with antiplatelet therapy, high-intensity statin therapy, blood pressure management, and lifestyle modifications are also crucial in the management of posterior circulation stroke.
From the Research
Clinical Manifestations of Posterior Circulation Stroke
The clinical manifestations of a posterior circulation stroke can be diverse and challenging to diagnose. Some key points to consider include:
- Posterior circulation strokes represent approximately 20% of all ischemic strokes 2, 3, 4, 5, 6
- The clinical presentation of posterior circulation strokes can be subtle and nonspecific, making diagnosis difficult 3, 5
- Patients with posterior circulation strokes are at risk of being misdiagnosed, which can lead to worse outcomes 5
- A fastidious history, physical exam, high clinical suspicion, and appropriate use of imaging are essential for proper diagnosis and treatment 4
- Understanding important anatomic variants, clinical presentations, and physical examination findings can help reduce misdiagnosis 5
Diagnostic Challenges
Some of the diagnostic challenges associated with posterior circulation strokes include:
- Distinguishing posterior circulation strokes from mimics 3
- Identifying patients who are likely to benefit from intervention based on imaging findings 3
- Recognizing the subtler presentations of posterior circulation ischemia, such as basilar stroke 5
- Being aware of the limitations of acute brain imaging in diagnosing posterior circulation strokes 5
Importance of Accurate Diagnosis
Accurate diagnosis of posterior circulation strokes is crucial to ensure timely and effective treatment. Some key points to consider include:
- Posterior circulation strokes can have a significant impact on patient disability and mortality 6
- Early diagnosis and treatment can improve outcomes for patients with posterior circulation strokes 3, 6
- Clinicians should have a heightened suspicion of posterior circulation events and implement timely, evidence-based management 3