ISCHEMIC STROKE

Created 20/06/2023, last revision 20/09/2023

• the vertebrobasilar (posterior) circulation comprises the vertebral, basilar, and posterior cerebral arteries, as well as their branches
• it supplies the posterior regions of the brain (brainstem, thalamus, cerebellum, and areas of the occipital and temporal lobes)
• the term vertebrobasilar insufficiency (VBI) describes inadequate blood flow through the posterior circulation
  • it may manifest either as a transient condition (transient ischemic attack (TIA), drop attack, Bow Hunter’s syndrome) or as a permanent condition (infarct)
  • several mechanisms leading to hypoperfusion may be involved and may even be combined (embolism, atherothrombosis, external mechanical compression, steal syndrome)
  • the term has been overused (often referring to various nonvascular vertiginous conditions in the geriatric population), and its use is discouraged
• vertebrobasilar ischemia shares features with other etiologies; DDx in the acute setting can be challenging
  • DDx of vertigo (labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo, etc.)
  • DDx of impaired consciousness (metabolic coma, nonconvulsive seizure, etc.)
• the outcome depends on the location and extent of the stenosis/occlusion, the quality of the collateral circulation, and adequate and timely therapy
  • mortality > 90% in untreated extensive basilar artery occlusions (BAO)
• posterior stroke is associated with a higher risk of recurrence compared to strokes in carotid territory
  • the risk of recurrence after a previous stroke/TIA with VA/BA stenosis ≥ 50% is approx. 22%/90 days [Marquardt, 2009]

→ arterial territories

→ anatomy of cerebral arteries

• the symptoms of a vertebrobasilar stroke can vary greatly among patients, depending on the type of occluded artery, the extent of occlusion, and the quality of the collateral circulation
• a combination of symptoms is common → see Topical diagnosis of stroke
• traditional brainstem syndromes have been described, but some symptoms may be nonspecific (DDx of vertigo)

• vestibular syndrome (vertigo, nystagmus, tonic deviations)
  • isolated vertigo is usually of nonvascular origin
  • nonspecific balance disorders must be distinguished (see below)
  • vertigo due to a stroke is usually accompanied by other brainstem and cerebellar symptoms
• nausea and vomitus
• eye movement disorder (nuclear/supranuclear) +/- diplopia
• visual field disturbances
• signs of sympathetic lesions
  • Horner’s syndrome (ptosis and miosis, sometimes anhidrosis on the affected side) 
  • Harlequin sign 
• ataxia and/or dysmetria
• dysarthria/dysphonia
• dysphagia
• paresthesia/hypesthesia in the face and/or extremities and trunk
• combination of paresis or sensory deficit in the extremities
  • hemiparesis or quadriparesis
• isolated hearing impairment is usually not caused by a stroke (except for the occlusion of the labyrinthine artery)
• alternating syndromes are typical for localized brainstem lesions with an ipsilateral nuclear lesion of a cranial nerve, Horner’s syndrome or cerebellar syndrome, and contralateral fascicular disorder (hemiparesis or hemihypesthesia)
• larger occlusions lead to impaired consciousness (coma may be the initial manifestation) → Examination of the patient with impaired consciousness
• transient circulatory disturbances may also lead to drop attacks

Etiologic classification of ischemic stroke

Diagnosis of a vertebrobasilar steno-occlusive disease

• the most frequent causes of vertebrobasilar stroke are atherosclerosis (AS) and arteriolopathy; cardioembolism is less common
  • AS lesions are most commonly located in the V0 and V4 segments of the vertebral arteries, in the proximal and middle segments of the basilar artery, and the P1 segment of the posterior cerebral artery (PCA)    
    
  • occlusion of a perforator results in lacunar stroke  
    
• arterial dissection most commonly affects the V3 segment 
  • typical presentations include neck or occipital pain +/- TIA or infarction
• stenosis can cause:
  • atherothrombotic occlusion
  • perforator occlusion
  • thromboembolism
  • hypoperfusion in distal segments
  • steal phenomenon
    • occurs in stenosis/occlusion of the proximal segments of the subclavian artery or brachiocephalic trunk
    • usually causes only transient symptoms (dizziness), not stroke
  • Bow-Hunter’s syndrome (also known as rotational vertebral artery syndrome) – transient ischemic symptoms caused by external mechanical compression of the vertebral artery (mostly at the C1-2 level) during lateral flexion or rotation of the head; often in combination with contralateral stenosis
• a less common cause of stroke is dolichoectasia and its complications 
  • flow stasis  increasing the likelihood of thrombus formation
  • arterial wall stress predisposing to dissection or even rupture
  • mass effect on adjacent neural structures

• diagnosis is based on a careful history with a detailed clinical examination and the correct indication and interpretation of imaging studies

• ischemia or bleeding in the brain stem and cerebellum does not usually cause diagnostic difficulties due to typical symptoms
• it is necessary to exclude a nonvascular etiology (external brainstem compression, brainstem tumor)
• isolated vertigo and altered consciousness presents considerable challenges due to the broad spectrum of potential etiologies involved

• not every vertigo is of vascular origin (especially in the elderly)
• dizziness should always be specified and accurately described – distinguish vestibular vertigo from various nonvestibular conditions, ataxia, or other balance disorders and psychogenic conditions
  • the term vertigo should be reserved for the dizziness of vestibular origin
  • distinguish other nonspecific disorders (weakness, fainting, blurred vision, or unsteady gait)
• to determine whether the dizziness is vestibular, nonvestibular, or caused by another balance disorder, we should obtain and evaluate the following:
  • an accurate description of the current condition, incl. associated symptoms (hearing impairment, lesions of other cranial nerves, brainstem, and cerebellar symptoms)
  • onset (sudden x gradual), duration, and provoking factors (e.g.,  head or body movement or position)
  • course (constant x fluctuating, spontaneous worsening x improving)
• consider the age of the patient

• these possibilities must be distinguished based on the patient’s history:
  • true vertigo (usually rotational) caused by vestibular pathway dysfunction (central or peripheral)
  • balance disorder without rotatory vertigo
    • instability manifesting mainly when walking or standing; symptoms typically alleviate when sitting or lying down
    • the absence of rotational vertigo suggests a nonvestibular etiology
  • presyncope (fainting) and other nonspecific symptoms
    • feeling of impending fainting but without actual loss of consciousness, lightheadedness or general malaise
    • e.g., due to hypoglycemia, hyperventilation, anemia, side effects of drugs, etc.
• exclude vascular etiology, especially in elderly patients with vascular risk factors, and look for subtle lesions on neuroimaging (perform DWI if possible)