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Current Endovascular Strategies for Posterior Circulation Large Vessel J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-014873 on 18 May 2019. Downloaded from Standards Current endovascular strategies for posterior circulation large vessel occlusion stroke: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee Yasha Kayan, 1 Philip M Meyers,2 Charles J Prestigiacomo,3 Peter Kan,4 Justin F Fraser, 5 on Behalf of the Society of NeuroInterventional Surgery 1Neurointerventional Radiology, ABSTRact on revascularization of the occlusion.13 14 Lindsberg Abbott Northwestern Hospital, Background The aim of this publication is to provide et al report good clinical outcomes with recanali- Minneapolis, Minnesota, USA 15 2 zation in 38% versus 2% without recanalization. Neurointerventional Surgery, a detailed update on the diagnosis, treatment, and Columbia Presbyterian Hospital, endovascular techniques for posterior circulation From the Helsinki Stroke Thrombolysis Registry, New York City, New York, USA emergent large vessel occlusion (pc-ELVO). Sairanen et al report good clinical outcomes with 3Neurological Surgery, University Methods We performed a review of the literature to recanalization in 86% versus 14% without reca- of Cincinnati, Cincinnati, Ohio, specifically evaluate this disease and its treatments. nalization.7 Similarly, Kumar et al report 1.5 times USA 4Department of Neurosurgery, Results Data were analyzed, and recommendations decreased dependency and two times decreased 14 Baylor College of Medicine, were reported based on the strength of the published mortality with recanalization than without it. Houston, Texas, USA evidence and expert consensus. With these data in mind, the aims of this docu- 5 Neurological Surgery, University Conclusion While many questions about pc-ELVO ment include: (1) to review data on the natural of Kentucky, Lexington, history and outcomes from pc-ELVO and (2) Kentucky, USA remain to be studied, there is evidence to support particular practices in its evaluation and treatment. to provide guidelines and recommendations on Correspondence to acute intervention regarding pc-ELVO (figure 1). Dr Justin F Fraser, Neurological Recommendations follow the American College Surgery, University of Kentucky, of Cardiology/American Heart Association (ACC/ INTRODUCTION 800Rose St Room MS105A, AHA) classification of recommendation and level Posterior circulation strokes account for approxi- Lexington, KY40536, USA; of evidence.16 Jfr235@ uky. edu mately 20% of all strokes, but posterior circulation emergent large vessel occlusions (pc-ELVO) are Received 22 February 2019 rare, representing only 1% of all ischemic strokes, DIAGNOSIS Revised 17 April 2019 1–3 Accepted 22 April 2019 and 5% of all ELVOs. These strokes are often Clinical presentation devastating events. Good clinical outcomes occur The clinical presentation of posterior circulation in approximately 20% despite advanced care, and strokes can be non-specific. Common symptoms the rate of good clinical outcome after revascu- can include loss of consciousness, headache, nausea, larization has been lower than for anterior circu- vomiting, dizziness, double vision, hearing loss, http://jnis.bmj.com/ lation stroke.4–6 A number of reasons account for slurred speech, vertigo, imbalance, and unilateral this disparity. Unlike hemispheric ischemia, basilar extremity weakness. Physical examination may also artery occlusion can mimic other clinical condi- commonly reveal ataxia, nystagmus, and visual field 17 tions, resulting in delays to clinical neurological defects. BAO vary based on thrombus location. evaluation and identification.7 There may be an Top of the basilar syndrome includes somnolence, extended prodrome that can potentially last days to peduncular hallucinosis, convergence nystagmus, on September 29, 2021 by guest. Protected copyright. months.8 9 Furthermore, the neurologic ‘real estate’ skew deviation, oscillatory eye movements, retrac- involved in brainstem ischemia is more eloquent; a tion and elevation of the eyelids, and vertical gaze small completed infarction can be clinically devas- paralysis. Mid-basilar occlusions can result in the tating. Etiologies for posterior circulation isch- various pontine syndromes. Proximal basilar occlu- 17 emia include thromboembolism (often in younger sions can result in ‘locked in’ syndrome. age), intrinsic atherosclerosis (usually sixth/seventh decades of life), dissection with basilar embolism Prehospital ELVO scales (often in trauma), and vasculitidies.8 10 These factors Recent prehospital stroke scales were designed for © Author(s) (or their all require consideration in the assessment of acute anterior circulation strokes. In the evaluation of employer(s)) 2019. No stroke referable to the posterior circulation. the Los Angeles Motor Scale, sensitivity and speci- commercial re-use. See rights Basilar artery occlusion (BAO) syndrome pres- ficity in 119 patients to detect ELVO were 81% and and permissions. Published by BMJ. ents as a subtype of posterior circulation stroke. 89%, respectively, but excluded posterior circula- While there is large practice variability among tion strokes.18Rapid Arterial Occlusion Evaluation To cite: Kayan Y, Meyers PM, interventionalists on time limits for thrombectomy was found to have a similar ELVO sensitivity and Prestigiacomo CJ, et al. in this syndrome, good clinical outcomes have specificity (85% and 65%, respectively) in a cohort J NeuroIntervent Surg Epub ahead of print: [please been demonstrated up to 50 hours from last known of 357 patients, but only 7% had posterior circu- 11 19 include Day Month Year]. well. Stroke severity at presentation is an inde- lation stroke. While it has recently been shown doi:10.1136/ pendent predictor of patient outcome.12 However, that adding the finger to nose test to the Cincin- neurintsurg-2019-014873 good outcomes appear to depend, at least in part, nati Prehospital Stroke Scale significantly increased Kayan Y, et al. J NeuroIntervent Surg 2019;0:1–8. doi:10.1136/neurintsurg-2019-014873 1 J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-014873 on 18 May 2019. Downloaded from Standards successful basilar artery thrombolysis in 1982, and Hacke et al reported the clinical outcome benefit of revascularization in a series of 65 patients 6 years later in 1988.26 27 Advancement in non-invasive imaging permitted understanding of variances in outcome. The New England Stroke Registry showed that 29% of patients with posterior circulation strokes died or suffered severe disability; however, individuals with embolic strokes fared worse than those with in situ atherosclerosis.8 However, reported mortality ranges from 45% to 86%.4 15 28 Predictors of poor outcome include older age, higher NIHSS score, lack of Figure 1 Flow chart illustrating the workflow from the summary recanalization, atrial fibrillation, intracranial hemorrhage, and of recommendations. CTA, CT angiography; DWI, diffusion weighted posterior circulation Alberta Stroke Program Early CT Score imaging; IA, intra-arterial. (pc-ASPECTS) ≤8.29 As with anterior circulation strokes, hemorrhagic conversion is related to the overall volume of the infarction, use of antico- the recognition of posterior circulation strokes by paramedics agulants (eg, heparin) in the peri-ictal setting, and administration in a cohort of 789 consecutive ischemic stroke cases, pc-ELVO of fibrinolytics. In a small study that reviewed 37 patients with remains difficult to detect in the field.20 posterior circulation strokes who were administered heparin, 11% developed hemorrhagic conversions. All patients who Limitations of the NIHSS in pc-ELVO worsened sustained a proximal to mid-basilar artery occlusion Limitations of the National Institutes of Health Stroke Scale and cerebellar infarction.30 In a retrospective review of almost (NIHSS) include a focus on limb and speech impairments and 1000 patients in the TIMS-China registry, multivariate analysis 21 less emphasis on cranial nerve lesions. In a prospective cohort suggested a lower 3.2% incidence of symptomatic hemorrhagic of 310 stroke patients not treated with thrombolysis, baseline conversion in 124 patients with posterior circulation strokes NIHSS cut-off for a favorable 3 month outcome (modified compared with 7.7% in patients with anterior circulation Rankin Scale (mRS) score of ≤2) was significantly lower in strokes.31 Moreover, a higher proportion of functional indepen- patients with posterior circulation stroke compared with ante- dence was noted after hemorrhagic conversion in patients with 22 rior circulation stroke. Indeed, patients with pc-ELVO can posterior circulation strokes when compared with patients with have an NIHSS score of 0, where symptoms may be headache, anterior circulation strokes (64% vs 53%, OR 2.33, 95% CI 1.40 vertigo, and nausea only. The most common neurological sign in to 3.89). a series of 20 NIHSS 0, diffusion weighted imaging (DWI) posi- 23 tive patients was truncal ataxia. Therefore, the physician must IMAGING maintain a high index of clinical suspicion for this condition in Computed tomography the face of subtle symptoms. Non-contrast CT is used to exclude hemorrhage and evaluate for other intracranial abnormalities, including life-threatening Clinical confounders and differential diagnosis edema and mass effect in the posterior fossa. Beam hardening Posterior circulation strokes presenting to an emergency depart- artifact often limits assessment of structures in the posterior fossa ment may be associated with a delay
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