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Symptoms and Signs of Posterior Circulation Ischemia in the New England Medical Center Posterior Circulation Registry

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Symptoms and Signs of Posterior Circulation Ischemia in the New England Medical Center Posterior Circulation Registry ORIGINAL CONTRIBUTION ONLINE FIRST Symptoms and Signs of Posterior Circulation Ischemia in the New England Medical Center Posterior Circulation Registry D. Eric Searls, MD; Ladislav Pazdera, MD; Evzen Korbel, MA; Oldrich Vysata, MD, PhD; Louis R. Caplan, MD Objective: To evaluate the frequencies of symptoms and (41%), dysarthria (31%), headache (28%), and nausea signs in patients with posterior circulation ischemia in a or vomiting (27%). The most frequent signs were uni- large case series of prospectively collected patients. lateral limb weakness (38%), gait ataxia (31%), unilat- eral limb ataxia (30%), dysarthria (28%), and nystag- Design: Case series. mus (24%). Logistic regression analysis reveals that the clinical features dysphagia (P=.004; 95% CI, 1.8-24.4), Setting: Outpatient and inpatient setting at the New En- nausea or vomiting (P=.002; 95% CI, 1.6-8.2), dizzi- gland Medical Center, a tertiary care referral center in ness (P=.047; 95% CI, 1.0-5.4), and Horner syndrome Boston, Massachusetts. (P=.001; 95% CI, 2.4-26.6) were positively correlated with the proximal vascular territory. Unilateral limb weak- Patients: Consecutive sample of 407 adult patients who ness (P=.001; 95% CI, 1.7-8.7) and cranial nerve VII defi- had stroke and/or transient ischemic attacks in the pos- cits (P=.02; 95% CI, 1.1-5.3) were positively correlated terior circulation within 6 months of study inclusion. All with the middle territory. Limb sensory deficit (P=.001; patients were examined by senior stroke neurologists. All 95% CI, 1.8-7.8), lethargy (P=.001; 95% CI, 2.3-12.4), patients had either computed tomography or magnetic and visual field loss (P=.001; 95% CI, 5.3-23.9) were posi- resonance imaging of the brain as well as vascular imaging tively correlated with the distal territory. of the head and neck. The study included 256 men (63%) and 151 women (37%). Conclusions: We report the most frequent symptoms and signs in the largest published registry, the New En- Main Outcome Measures: Frequencies of posterior gland Medical Center Posterior Circulation Registry, of circulation ischemic symptoms and signs. These out- patients with posterior circulation ischemia who had com- come measures were planned before data collection be- plete neurological examinations and extensive cerebro- gan. Correlations between symptoms and signs with sepa- vascular imaging. Knowledge of the vascular territory in- rate vascular territories of the posterior circulation were volved aids in the diagnosis of the causative vascular lesion then analyzed. and stroke mechanism. Results: The most frequent posterior circulation symp- Arch Neurol. 2012;69(3):346-351. Published online toms were dizziness (47%), unilateral limb weakness November 14, 2011. doi:10.1001/archneurol.2011.2083 YMPTOMS AND SIGNS TAKE brobasilar disease was not confirmed by center stage during the clini- angiography or other vascular imaging.1-4 cal encounter. They provide In other series, symptoms and signs were the basis for clinical diagno- reported in patients with specific sub- Author Affiliations: sis. Separation of transient types of posterior circulation ischemic dis- Author Affil Department of Neurology, and persistent brain ischemia from other ease (eg, basilar artery occlusion, lateral Department Harvard Medical School, and S Harvard Med neurological causes as well as localiza- medullary infarction, cerebellar infarc- Division of Cerebrovascular tion of the findings to the anterior or pos- tion). More recently, a prospective study Division of C Disease, Beth Israel Deaconess Disease, Beth terior circulation are based on symptoms of 116 patients with posterior circulation Medical Center, Boston, 5 Medical Cen Massachusetts (Drs Searls and and signs and are important to effectively ischemia from Qatar was published. Massachuset Caplan); and Department of plan brain and vascular imaging and other We analyzed the symptoms and signs Caplan); and Computing and Control investigations. Past estimates of the fre- in a prospectively collected large data- Computing a Engineering, Institute of quency, sensitivity, and specificity of vari- base of patients with posterior circula- Engineering Chemical Technology, Prague, ous clinical findings in patients sus- tion transient ischemic attacks (TIAs) and Chemical Te Czech Republic (Dr Vysata). Czech Repub Dr Pazdera is in private practice pected of having vertebrobasilar occlusive strokes. From 1988 to 1996 at the New En- Dr Pazdera i in Rychnov nad Kne˘zˇnou, disease were not based on documenta- gland Medical Center, Boston, Massachu- in Rychnov n Czech Republic. Mr Korbel has tion of posterior circulation infarction. In setts, we extensively evaluated 407 pa- Czech Repub no current academic affiliation. some early series, the diagnosis of verte- tients with posterior circulation ischemia no current a ARCH NEUROL / VOL 69 (NO. 3), MAR 2012 WWW.ARCHNEUROL.COM 346 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 using brain imaging, vascular imaging (initially digital subtraction dye angiography and later magnetic reso- Upper nance angiography), and relevant cardiac and hemato- PCA logical studies. Patient data were entered into the New England Medical Center Posterior Circulation Registry (NEMC-PCR). Previous reports from this registry ana- lyzed risk factors, distribution of infarcts, mechanisms of ischemia, location of occlusive vascular lesions, and SCA outcomes.2-4,6-17 Middle METHODS Basilar AICA The NEMC-PCR, which consisted of patients collected from 1988 to 1996, had 3 major inclusion criteria. First, all patients were examined by 3 senior stroke neurologists. Second, all pa- tients must have had strokes or TIAs in the posterior circula- tion within the prior 6 months. Strokes must have been docu- PICA VA mented by computed tomography or magnetic resonance VA imaging (MRI) of the brain (Ͼ80% had MRI of the brain). The Lower TIAs were in the vertebrobasilar territory with vascular imaging demonstrating vertebrobasilar occlusive lesions. Third, all in- vestigations needed to be adequate. The NEMC-PCR data included demographic characteristics and risk factors as described in a prior article.4 The following data were also recorded: stroke localization, vascular lesions, stroke mechanisms, cause of vascular, cardiac, and hematological con- ditions, and outcome data. All patients had head and neck vas- cular imaging (80% had conventional angiograms). Extracranial Figure 1. Drawing of the anterior surface of the brainstem showing the ultrasonography was used extensively, and more than 80% of pa- basilar artery, vertebral arteries (VAs), and their branches. The region is divided into the distal intracranial territory, middle intracranial territory, and tients had transcranial Doppler ultrasonography performed. Car- proximal intracranial territory. AICA indicates anterior inferior cerebellar diac studies included electrocardiography, transthoracic echo- artery; PCA, posterior cerebral artery; PICA, posterior inferior cerebellar cardiography, transesophageal echocardiography, and/or 24- artery; and SCA, superior cerebellar artery. Adapted with permission.2 hour rhythm monitoring. Each case was reviewed at least twice to ensure accurate data entry as well as correct and complete di- agnoses. The criteria for stroke mechanisms were described in a RESULTS previous article.4 The location of ischemic events was determined clinically The NEMC-PCR included 256 men (63%) and 151 and by brain imaging. In the NEMC-PCR, brain lesions were categorized as involving proximal, middle, and distal intracra- women (37%). The average age was 60.5 years. At pre- nial posterior circulation territories. The proximal territory in- sentation, 100 subjects were outpatients and 307 were cluded regions supplied by the intracranial vertebral artery— inpatients. Strokes without TIA occurred in 240 pa- the medulla oblongata and the posterior inferior cerebellar tients (59%). Ninety-eight patients (24%) had a TIA be- artery–supplied region of the cerebellum. The middle terri- fore stroke, and 4 patients (1%) had a TIA after stroke. tory included brain regions supplied by the basilar artery up Sixty-five patients (16%) had only a TIA. to its superior cerebellar artery branches—the pons and ante- Three hundred thirty-nine patients (83%) had terri- rior inferior cerebellar artery–supplied region of the cerebel- torial infarcts on brain imaging. Another 8 patients had lum. The distal territory included regions supplied by the ros- signs localizing to 1 intracranial territory. The most fre- tral basilar artery, superior cerebellar artery, posterior cerebral quent location of single-territory infarcts was the distal artery, and their penetrating artery branches—midbrain, thala- mus, superior cerebellar artery–supplied cerebellum, and pos- intracranial territory (143 patients). Fifty-six patients had terior cerebral artery territories. The distribution of territories infarcts localized to the middle intracranial territory, and is shown in Figure 1.2 62 patients had infarcts localized to the proximal intra- We analyzed the frequency of various symptoms and signs cranial territory. Eighty-three patients had infarcts in mul- that occurred at or soon after presentation in patients with pos- tiple territories. The percentages of infarcts in the proxi- terior circulation ischemia. We also analyzed the frequencies mal, middle, distal, and multiple territories were 18%, of symptoms and signs of infarcts in each of the 3 vascular
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