What is the management approach for a patient with posterior circulation stroke presenting with vision loss?

Management of Posterior Circulation Stroke with Vision Loss

For patients with posterior circulation stroke presenting with vision loss, immediate neuroimaging with MRI (preferred) or CT, vascular imaging from aortic arch to vertex, and prompt initiation of appropriate reperfusion therapy are essential, followed by comprehensive secondary prevention measures including antiplatelet therapy and risk factor modification. 1

Immediate Evaluation and Diagnosis

• Brain Imaging: MRI with diffusion-weighted imaging is preferred over CT for posterior fossa lesions due to superior visualization of brainstem and cerebellar structures 1, 2
• Vascular Imaging: Angiography from aortic arch to vertex by CT or MRI to identify occlusion location and etiology 1
• Cardiac Evaluation: ECG and echocardiogram to evaluate for cardioembolic sources 1
• Laboratory Tests: Complete blood count, chemistry panel, lipid profile, ESR and CRP (to rule out giant cell arteritis) 1

Acute Management

Reperfusion Therapy

• Intravenous Thrombolysis: Similar benefits with lower hemorrhage risks compared to anterior circulation strokes 3
• Endovascular Thrombectomy: Recent evidence from ATTENTION and BAOCHE trials supports thrombectomy for basilar artery occlusion 3, 4
  • Time window may be longer for basilar artery thrombosis compared to anterior circulation 2
  • Consider for patients with:
    • Confirmed basilar artery occlusion
    • Salvageable brain tissue on imaging
    • Presentation within treatment window

Management of Vision Loss

• Ophthalmological Evaluation: Immediate assessment including fundus examination and optical coherence tomography (OCT) 1
• Central Retinal Artery Occlusion (CRAO): Manage as a form of ischemic stroke with multidisciplinary approach 1
• Visual Field Defects: Document baseline deficits for monitoring recovery and rehabilitation planning 5

Secondary Prevention

Pharmacological Management

• Antiplatelet Therapy: Initiate promptly; dual antiplatelet therapy reasonable for CRAO in patients with recent stroke 1
• Statin Therapy: For hyperlipidemia management and plaque stabilization 1
• Anticoagulation: Only if atrial fibrillation or other cardioembolic source is detected 1

Risk Factor Modification

• Hypertension Management: Aggressive blood pressure control is essential 1
• Other Modifiable Factors: Treatment of dyslipidemia, diabetes, obesity, obstructive sleep apnea; smoking cessation; plant-based diet; regular physical activity 1

Vascular Intervention

• Carotid Endarterectomy: Recommended for significant carotid stenosis, ideally within 14 days 1
• Intracranial Stenting: RCT data suggest basilar artery stenosis is better treated with medical therapy than stenting due to high procedural risk 3
• Vertebral Artery Stenosis: Limited evidence; extracranial stenosis may be considered for stenting with recurrent symptoms despite medical therapy 3

Follow-up and Rehabilitation

• Neurological Follow-up: Within 2 weeks to review test results and optimize secondary prevention 1
• Ophthalmological Monitoring: Regular assessment for:
  • Residual vision
  • Neovascularization complications
  • Health of contralateral eye 1
• Visual Rehabilitation: For patients with significant vision loss 1
• Multidisciplinary Care: Coordination between neurologist, ophthalmologist, primary care physician, and rehabilitation specialists 1

Clinical Pearls and Pitfalls

• Diagnostic Challenges: Posterior circulation strokes can present with non-specific symptoms (headache, dizziness, nausea) that may delay diagnosis 6, 2
• Varied Presentations: Visual symptoms may include homonymous hemianopia, cortical blindness, or visual field cuts depending on the location of infarction 5
• Basilar Occlusion Variants: "Top of the basilar syndrome" can cause visual hallucinations and vertical gaze abnormalities; mid-basilar occlusions affect pontine structures; proximal occlusions may cause "locked-in" syndrome 6
• Cerebellar Stroke: Monitor for edema and potential need for decompressive craniectomy in space-occupying cerebellar strokes 3
• High Recurrence Risk: Posterior circulation strokes have a high chance of recurrence, emphasizing the importance of aggressive secondary prevention 2