1. Posterior Circulation Stroke Christopher Lewandowski, M.D. Sunitha Santhakumar, M.D. Henry Ford Hospital Detroit, Michigan Christopher Lewandowski, M.D. Sunitha Santhakumar, M.D. Henry Ford Hospital Detroit, Michigan

2. Christopher Lewandowski, MD Case Study HPI:HPI: The patient is 41 y.o. male, with a past history of alcohol abuse, hypertension who presents to the ED with a chief complaint of right -sided weakness, slurred speech, and loss of balance. The symptoms began 90 minutes prior to arrival HPI:HPI: The patient is 41 y.o. male, with a past history of alcohol abuse, hypertension who presents to the ED with a chief complaint of right -sided weakness, slurred speech, and loss of balance. The symptoms began 90 minutes prior to arrival

3. Christopher Lewandowski, MD Case Study PMHx:PMHx: Alcohol Abuse, quit for 3 years Hypertension Seizures, Generalized, none for past 7 years MedicationsMedicationsDyazide Social HxSocial Hx Smoking- 2 pack per day ROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutesROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutes PMHx:PMHx: Alcohol Abuse, quit for 3 years Hypertension Seizures, Generalized, none for past 7 years MedicationsMedicationsDyazide Social HxSocial Hx Smoking- 2 pack per day ROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutesROS: Mild dizzy spells for the past 2 weeks, each lasting 5-10 minutes

4. Christopher Lewandowski, MD Case Study Physical Exam: BP- 149/79, P-100, RR-18, T-36.9 A& Ox3 on presentation, later became stuporous CN: dysarthria, pupils: R 3.5/ L 3.0 reactive L facial droop, gaze palsy to the L Motor: R arm and R leg weakness (3/5) Sensory: Decreased to light touch and pinprick on R Coordination: dysmetria on R (not out of proportion to weakness) NIH Stroke Scale score = 14 Physical Exam: BP- 149/79, P-100, RR-18, T-36.9 A& Ox3 on presentation, later became stuporous CN: dysarthria, pupils: R 3.5/ L 3.0 reactive L facial droop, gaze palsy to the L Motor: R arm and R leg weakness (3/5) Sensory: Decreased to light touch and pinprick on R Coordination: dysmetria on R (not out of proportion to weakness) NIH Stroke Scale score = 14

5. Christopher Lewandowski, MD What does this patient have? Differential DiagnosisDifferential DiagnosisStroke Intracerebral Hemorrhage TumorVBIMigraineSeizure Differential DiagnosisDifferential DiagnosisStroke Intracerebral Hemorrhage TumorVBIMigraineSeizure

6. Christopher Lewandowski, MD Posterior Circulation Stroke: Characteristics ProdromeProdrome Occurs in about 60 % of patients with Basilar artery thrombosis Common Prodromal Symptoms (in order of frequency)Common Prodromal Symptoms (in order of frequency) Vertigo and Nausea(30%) Headache, Neckache(20%) Hemiparesis(10%) Dysarthria, Diplopia(10%) Hemianopia(6%) Ferbert, Stroke 1990 ProdromeProdrome Occurs in about 60 % of patients with Basilar artery thrombosis Common Prodromal Symptoms (in order of frequency)Common Prodromal Symptoms (in order of frequency) Vertigo and Nausea(30%) Headache, Neckache(20%) Hemiparesis(10%) Dysarthria, Diplopia(10%) Hemianopia(6%) Ferbert, Stroke 1990

7. Christopher Lewandowski, MD Was this Patient’s Dizziness Central or Peripheral CentralPeripheral IntensityMildSevere TinnitisRareCommon CN findingsFrequentNone Nystagmus: Visual fixationNo inhibitionInhibits Purely horiz.CommonRare Latency None3-40 sec FatigueNoneyes CentralPeripheral IntensityMildSevere TinnitisRareCommon CN findingsFrequentNone Nystagmus: Visual fixationNo inhibitionInhibits Purely horiz.CommonRare Latency None3-40 sec FatigueNoneyes

8. Christopher Lewandowski, MD Posterior Circulation Stroke: Characteristics Clinical Findings: The 5 Ds:Dizziness, Diplopia, Dysarthria, Dysphagia, Dystaxia Hallmarks: Crossed findings Cranial nerve deficits - Ipsilateral Motor / Sensory deficits - Contralateral Clinical Findings: The 5 Ds:Dizziness, Diplopia, Dysarthria, Dysphagia, Dystaxia Hallmarks: Crossed findings Cranial nerve deficits - Ipsilateral Motor / Sensory deficits - Contralateral

9. Christopher Lewandowski, MD Posterior Circulation Stroke: Syndromes

10. Christopher Lewandowski, MD Posterior Circulation Stroke: Anatomy

11. Christopher Lewandowski, MD Posterior Circulation Stroke: Anatomy

12. Christopher Lewandowski, MD How do you evaluate this patient Confirm the Diagnosis (Emergent)Confirm the Diagnosis (Emergent) CT Scan MRI Blood Studies Evaluation of Stroke Etiology (Inpatient)Evaluation of Stroke Etiology (Inpatient) MRA / Angiography Echo / TEE TCD Carotid Doppler Confirm the Diagnosis (Emergent)Confirm the Diagnosis (Emergent) CT Scan MRI Blood Studies Evaluation of Stroke Etiology (Inpatient)Evaluation of Stroke Etiology (Inpatient) MRA / Angiography Echo / TEE TCD Carotid Doppler

13. Christopher Lewandowski, MD Case Study: CT Scan

14. Christopher Lewandowski, MD Case Study: MRI - DWI <12 Hours 4 Days

15. Christopher Lewandowski, MD Posterior Circulation Stroke: Prognosis All Posterior Circulation StrokesAll Posterior Circulation Strokes New England Medical Center Posterior Circulation Stroke Registry: Mortality = 4% Minor or no Disability = 79% Locked In SyndromeLocked In Syndrome Mortality > 90% All Posterior Circulation StrokesAll Posterior Circulation Strokes New England Medical Center Posterior Circulation Stroke Registry: Mortality = 4% Minor or no Disability = 79% Locked In SyndromeLocked In Syndrome Mortality > 90%

16. Christopher Lewandowski, MD Posterior Circulation Stroke: Treatment Conservative TreatmentConservative Treatment Antiplatelet and Antithrombotic Thrombolytic TreatmentThrombolytic Treatment Intravenous: if the patient presents within 3 hours symptom onset and meets all treatment criteria Intra-Arterial Therapy: local infusion of thrombolytic agent into vessel or clot Conservative TreatmentConservative Treatment Antiplatelet and Antithrombotic Thrombolytic TreatmentThrombolytic Treatment Intravenous: if the patient presents within 3 hours symptom onset and meets all treatment criteria Intra-Arterial Therapy: local infusion of thrombolytic agent into vessel or clot

17. Christopher Lewandowski, MD Posterior Circulation Stroke: Treatment Conservative TreatmentConservative Treatment Antiplatelet and Anti thrombotic Therapy Uncontrolled, Retrospective Studies, 1950s & 1960s Compared to historical controls, patients treated with heparin had lower mortality (8-15% vs. 40-60%) Stopped progression of VBI to infarction TOAST TrialTOAST Trial No evidence to support heparinization in acute stroke Conservative TreatmentConservative Treatment Antiplatelet and Anti thrombotic Therapy Uncontrolled, Retrospective Studies, 1950s & 1960s Compared to historical controls, patients treated with heparin had lower mortality (8-15% vs. 40-60%) Stopped progression of VBI to infarction TOAST TrialTOAST Trial No evidence to support heparinization in acute stroke

18. Christopher Lewandowski, MD Posterior Circulation Stroke: Treatment Intravenous ThrombolysisIntravenous Thrombolysis NINDS rt-PA Acute Stroke Trial t-PA approved within 3 hours of symptom onset few posterior circulation strokes How do you know if a patient will progress to locked-in syndromeHow do you know if a patient will progress to locked-in syndrome Intravenous ThrombolysisIntravenous Thrombolysis NINDS rt-PA Acute Stroke Trial t-PA approved within 3 hours of symptom onset few posterior circulation strokes How do you know if a patient will progress to locked-in syndromeHow do you know if a patient will progress to locked-in syndrome

19. Christopher Lewandowski, MD Posterior Circulation Stroke: Treatment Intra-arterial Thrombolysis, LocalIntra-arterial Thrombolysis, Local No randomized controlled trials completed Multiple small series and reports Results (Over 200 patients treated)Results (Over 200 patients treated) Mortality 20-60%, assoc. with lack of recanalization Favorable outcomes in 25%-60% ICH rate low, 0-15% Intra-arterial Thrombolysis, LocalIntra-arterial Thrombolysis, Local No randomized controlled trials completed Multiple small series and reports Results (Over 200 patients treated)Results (Over 200 patients treated) Mortality 20-60%, assoc. with lack of recanalization Favorable outcomes in 25%-60% ICH rate low, 0-15%

20. Christopher Lewandowski, MD Posterior Circulation Stroke Future Treatment Intra-arterial ThrombolysisIntra-arterial Thrombolysis Superselective approach, micro-catheters AngioplastyAngioplasty Angio-jetAngio-jet Intra-arterial ThrombolysisIntra-arterial Thrombolysis Superselective approach, micro-catheters AngioplastyAngioplasty Angio-jetAngio-jet

21. Christopher Lewandowski, MD Case Study: Outcome The patient received intravenous thrombolysis after his mental status deteriorated with a NIH-SS score of 22The patient received intravenous thrombolysis after his mental status deteriorated with a NIH-SS score of 22 He improved initially, but without complete resolution of symptomsHe improved initially, but without complete resolution of symptoms On day 4, the NIH - SS score was 10On day 4, the NIH - SS score was 10 MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized,MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized, Cardiac evaluation was negativeCardiac evaluation was negative He was discharged on Coumadin to RehabHe was discharged on Coumadin to Rehab The patient received intravenous thrombolysis after his mental status deteriorated with a NIH-SS score of 22The patient received intravenous thrombolysis after his mental status deteriorated with a NIH-SS score of 22 He improved initially, but without complete resolution of symptomsHe improved initially, but without complete resolution of symptoms On day 4, the NIH - SS score was 10On day 4, the NIH - SS score was 10 MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized,MRA : L sup. cerebellar art. and R&L Ant-Inf cerebellar arteries were non-visualized, Cardiac evaluation was negativeCardiac evaluation was negative He was discharged on Coumadin to RehabHe was discharged on Coumadin to Rehab