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Treatment of posterior circulation stroke: Acute management and secondary prevention.

ABSTRACT: One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulation stroke differs from that of stroke in general and highlight recent advances.Effectiveness of acute revascularization of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower hemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy.Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions and short-term dual anti-platelet therapy. Randomized controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

SUBMITTER: Markus HS

PROVIDER: S-EPMC9358302 | biostudies-literature | 2022 Aug

REPOSITORIES: biostudies-literature

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Treatment of posterior circulation stroke: Acute management and secondary prevention.

Markus Hugh S HS Michel Patrik P

International journal of stroke : official journal of the International Stroke Society 20220628 7

One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulatio ...[more]

PMID: 35658624

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Project description:Background and purposeWe investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients.MethodsWe retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0-2) were compared between the ACS and PCS groups for each etiology.ResultsWe included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group.ConclusionsThe proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Project description:Background and purposePatients with posterior circulation acute ischemic stroke exhibit varied clinical presentations and functional outcomes. Whether posterior circulation acute stroke prognosis early computed tomography scores (PC-ASPECTS) predict unfavorable functional outcomes (UFO) for patients treated with different therapeutic regimens is unclear.MethodsAccording to PRISMA guidelines, we performed a systematic search of electronic databases for studies assessing the functional outcomes of posterior circulation acute ischemic stroke using baseline PC-ASPECTS. The following three scales of PC-ASPECTS were retrieved: UFO prediction by using PC-ASPECTS per score decrease, UFO prediction by using binary PC-ASPECTS with a cut-off value, and the difference in PC-ASPECTS between patients with unfavorable and favorable functional outcomes. Moreover, a subgroup analysis was conducted for patients treated with intra-arterial endovascular treatment (IA-EVT) only. Sensitivity analysis with different definition of UFO and image modalities were also conducted.ResultsIn total, 25 studies were included. In scale 1, PC-ASPECTS significantly predicted UFO (odds ratio [OR]: 1.66 per score decrease, 95% confidence interval [CI]: 1.32-2.07). In scale 2, binary PC-ASPECTS with a cut-off value between 6 and 9 significantly predicted UFO (OR: 3.91, 95% CI: 2.54-6.01). In scale 3, patients with UFO had lower PC-ASPECTS than those with favorable outcomes (standardized mean difference [SMD]: -0.67, 95% CI: -0.8 to -0.55). For patients treated with IA-EVT only, the scales demonstrated consistent results. Sensitivity analysis showed PC-ASPECTS significantly predicted UFO in both definitions of modified Rankin Scale ≥ 3 and ≥ 4, and magnetic resonance imaging was preferred imaging modality for PC-ASPECTS evaluation.ConclusionBaseline PC-ASPECTS is effective in predicting UFO for patients with posterior circulation acute ischemic stroke treated with different therapeutic regimens.

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Treatment of posterior circulation stroke: Acute management and secondary prevention.

Publications

Treatment of posterior circulation stroke: Acute management and secondary prevention.

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