Abstract
BACKGROUND:Ischemic strokes account for 80 % of all strokes, and one of every five compromises the posterior circulation. The diagnosis is difficult, and the data available about the outcome and mortality are discordant in the literature.
OBJECTIVE:To investigate the clinicai outcome of patients at 180 days after posterior circulation ischemic stroke
METHODS:Patients with diagnosis of posterior circulation stroke admitted to Instituto Neurológico de Colombia between September 2017 to 2018 were prospective included. The functional outcome by modified Rankin scale score (mRS) was determined at 1-month, 6-month, and 12-month after disease onset.
RESULTS:68 patients were included. The median age was 61 years ± 17 and 60.3 % were male. 85 % had a baseline mRS ? 1, and 63 % had a baseline National Institute Stroke Scale (NIHSS) ? 4. Nine patients were taken to acute recanalization therapies (rtPA, endovascular therapy or both) and seven more delayed arteriography. Sixteen patients (23.5 %) demonstrated an improvement of four or more points over the baseline NIHSS. Forty-six patients (74.2 %) had an excellent outcome 0-1 at six months and 87,1 % were categorized favorable mRS (mRS 0-2). In the adjusted analysis an NIHSS > 4 was a predictor of an unfavorable outcome at 6-month (RR 6.4; IC95 % 2.9-14.2). Six patients died (9 %); four of them in relation to the current event or an ischemic stroke recurrence.
CONCLUSION:Most of the patients with posterior ischemic stroke have favorable outcomes and a low mortality. The baseline NIHSS is an independent prognostic risk factor.
References
Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage: a systematic analysis of the global burden of disease study 2017. Neuroepidemiology. 2020;54:171-9. https://doi.org/10.1159/000506396
Katan M, Luft A. Global burden of stroke. Semin Neurol. 2018;38:208-11. https://doi.org/10.1055/s-0038-1649503
Asivamosensalud. Así vamos en Salud, enfermedades crónicas no transmisibles. [19.03.2020]. Disponible en: https://asivamosensalud.org/indicadores/enfermedades-cronicas-notransmisibles/tasa-de-mortalidad-por-enfermedades
Ministerio de Salud y Protección social. Enfermedades cardiovasculares. [19.03.2020]. Disponible en: https://www.minsalud.gov.co/salud/Paginas/Enfermedades-cardiovasculares.aspx
Sparaco M, Ciolli L, Zini A. Posterior circulation ischaemic stroke-a review part I: anatomy, etiology and clinical presentations. Neurol Sci. 2019;40:1995-2006. https://doi.org/10.1007/s10072-019-03977-2
Schulz UG, Fischer U. Posterior circulation cerebrovascular syndromes: diagnosis and management. J Neurol Neurosurg Psychiatry. 2017;88:45-53. https://doi.org/10.1136/jnnp-2015-311299
Go S. Posterior circulation ischemic stroke. Mo Med. 2015;112:192-6.
Inoa V, Aron AW, Staff I, Fortunato G, Sansing LH. Lower NIH stroke scale scores are required to accurately predict a good prognosis in posterior circulation stroke. Cerebrovasc Dis. 2014;37:251-5. https://doi.org/10.1159/000358869
Olivato S, Nizzoli S, Cavazzuti M, Casoni F, Nichelli PF, Zini A. e-NIHSS: an expanded National Institutes of Health Stroke Scale weighted for anterior and posterior circulation strokes. J Stroke Cerebrovasc Dis . 2016;25:2953-7. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.08.011
Wall SD, Brant-Zawadzki M, Jeffrey RB, Barnes B. High frequency CT findings within 24 hours after cerebral infarction. AJR Am J Roentgenol. 1982;138:307-11. https://doi.org/10.2214/ajr.138.2.307
Sparaco M, Ciolli L, Zini A. Posterior circulation ischemic stroke-a review part II: imaging and acute treatment. Neurol Sci. 2019;40:2007-15. https://doi.org/10.1007/s10072-019-03936-x
Schönfeld MH, Ritzel RM, Kemmling A, Ernst M, Fiehler J, Gellißen S. Improved detectability of acute and subacute brainstem infarctions by combining standard axial and thinsliced sagittal DWI. PLoS ONE. 2018;13:e0200092. https://doi.org/10.1371/journal.pone.0200092
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2018;49:e46-110. https://doi.org/10.1161/STR.0000000000000158
Förster A, Gass A, Kern R, Griebe M, Hennerici MG, Szabo K. Thrombolysis in posterior circulation stroke: stroke subtypes and patterns, complications and outcome. Cerebrovasc Dis . 2011;32:349-53. https://doi.org/10.1159/000330346
Zhu X, Wang N, Lin H, Zhang P, Chen L, Zhang M, et al. Safety and efficacy of intravenous thrombolytic therapy in patients with acute posterior circulation stroke: A single-center study. J Stroke Cerebrovasc Dis . 2020;29:104537. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104537
Dor?ák T, Král M, Ša?ák D, Ka?ovský P. Intravenous thrombolysis in posterior circulation stroke. Front Neurol. 2019;10:417. https://doi.org/10.3389/fneur.2019.00417
Keselman B, Gdovinová Z, Jatuzis D, Melo TPE, Vilionskis A, Cavallo R, et al. Safety and outcomes of intravenous thrombolysis in posterior versus anterior circulation stroke: results from the safe implementation of treatments in stroke registry and meta-analysis. Stroke. 2020;51:876-82. https://doi.org/10.1161/STROKEAHA.119.027071
Wang F, Wang J, He Q, Wang L, Cao Y, Zhang H, et al. Mechanical thrombectomy for posterior circulation occlusion: a comparison of outcomes with the anterior circulation occlusion- a meta-analysis. J Atheroscler Thromb. 2020. https://doi.org/10.5551/jat.54221
Zhao W, Ma P, Zhao W, Yang B, Zhang Y, Song J, et al. The safety and efficacy of mechanical thrombectomy in posterior vs. anterior emergent large vessel occlusion: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis . 2020;29:104545. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104545
Kim SH, Lee J-Y, Kim DH, Ham JH, Song YK, Lim EJ, et al. Factors related to the initial stroke severity of posterior circulation ischemic stroke. Cerebrovasc Dis . 2013;36:62-8. https://doi.org/10.1159/000351512.
Gattringer T, Posekany A, Niederkorn K, Knoflach M, Poltrum B, Mutzenbach S, et al. Predicting early mortality of acute ischemic stroke. Stroke. 2019;50:349-56. https://doi.org/10.1161/STROKEAHA.118.022863
Tao WD, Kong FY, Hao ZL, Lin S, Wang DR, Wu B, et al. One-year case fatality and disability after posterior circulation infarction in a Chinese hospital-based stroke study. Cerebrovasc Dis . 2010;29:376-81. https://doi.org/10.1159/000281836
Han Y, Xu M, Zhao Y, Zhang Y. Long-term outcome and prognostic factors of posterior circulation ischemia patients: Results from a single center retrospective study. Vascular. 2020;28:25-30. https://doi.org/10.1177/1708538119866604
Sommer P, Posekany A, Serles W, Marko M, Scharer S, Fertl E, et al. Is functional outcome different in posterior and anteriorcirculation stroke? Stroke. 2018;49:2728-32. https://doi.org/10.1161/STROKEAHA.118.021785
Caplan L, Chung CS, Wityk R, Glass T, Tapia J, Pazdera L, et al. New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes. J Clin Neurol. 2005;1:14-30. https://doi.org/10.3988/jcn.2005.1.1.14
Ay H, Furie KL, Singhal A, Smith WS, Sorensen AG, Koroshetz WJ. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol. 2005;58:688-97. https://doi.org/10.1002/ana.20617
Glass TA, Hennessey PM, Pazdera L, Chang HM, Wityk RJ, Dewitt LD, et al. Outcome at 30 days in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2002;59:369-76. https://doi.org/10.1001/archneur.59.3.369
Lin SF, Chen CI, Hu HH, Bai CH. Predicting functional outcomes of posterior circulation acute ischemic stroke in first 36 h of stroke onset. J Neurol. 2018;265:926-32. https://doi.org/10.1007/s00415-018-8746-6
Sato S, Toyoda K, Uehara T, Toratani N, Yokota C, Moriwaki H, et al. Baseline NIH Stroke scale score predicting outcome in anterior and posterior circulation strokes. Neurology. 2008;70:2371-7. https://doi.org/10.1212/01.wnl.0000304346.14354.0b
Zeng Q, Tao W, Lei C, Dong W, Liu M. Etiology and risk factors of posterior circulation infarction compared with anterior circulation infarction. J Stroke Cerebrovasc Dis . 2015;24:1614-20. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.03.033
Frid P, Drake M, Giese AK, Wasselius J, Schirmer MD, Donahue KL, et al. Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study. J Neurol. 2020;267:649-58. https://doi.org/10.1007/s00415-019-09613-5
Libman RB, Kwiatkowski TG, Hansen MD, Clarke WR, Woolson RF, Adams HP. Differences between anterior and posterior circulation stroke in TOAST. Cerebrovasc Dis . 2001;11:311-6. https://doi.org/10.1159/000047659
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.