Mechanical thrombectomy for acute posterior cerebral artery stroke; Feasibility and predictors of outcome.

PURPOSE: The territorial involvement and the clinical benefit of endovascular therapy (EVT) of the posterior cerebral artery (PCA) occlusion may vary between patients. The purpose of this study was to investigate the feasibility of mechanical thrombectomy (MT) in isolated posterior cerebral artery occlusions (IPCAOs) and the prognostic factors of EVT. METHODS: Forty-eight patients with acute PCA occlusion who underwent EVT between Mar 2008 and Apr 2021 from 2 tertiary centers were retrospectively analyzed. Clinical characteristics, imaging and perfusion abnormalities, and angiographic and clinical outcomes were analyzed. Ischemic changes were assessed with the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS). Perfusion abnormalities were assessed using automated software for Tmax volume measurement and identification of Tmax involved in PCA eloquent areas. RESULTS: The IPCAO sites were P1 (n = 17) and P2 (n = 31). Overall successful recanalization (mTICI 2b/3) was achieved in 68.8% (33/48) and excellent outcome (90-day mRS 0-1) in 52.1% (25/48) of the patients. Excellent/non-excellent outcome was associated with male sex (p = 0.036), admission NIHSS (p = 0.002), pc-ASPECTS (p = 0.035), Tmax > 6 s involvement of the midbrain-thalamus (p = 0.008), first-line stent-retriever thrombectomy (p = 0.036), complete recanalization (p = 0.009), and modified first pass effect (FPE, p = 0.047). Tmax>6 s involvement of the midbrain-thalamus was an independent predictor for non-excellent outcome on multivariable analysis. CONCLUSION: Acute stroke from IPCAO may be successfully treated with EVT. Tmax > 6 s involvement of the midbrain-thalamus on perfusion imaging may be a predictor for clinical outcome.

A Juvenile Case of Bow Hunter's Syndrome Caused by Atlantoaxial Dislocation with Vertebral Artery Dissecting Aneurysm.

BACKGROUND: Bow hunter's syndrome (BHS) is caused by posterior circulation insufficiency that results from the occlusion or compression of the vertebral artery (VA) during neck rotation. Owing to its rarity, there is no guideline to support the decision of selecting a conservative or a surgical approach. Management of BHS is dependent on each patient. CASE DESCRIPTION: A 13-year-old girl presented with transient visual disturbance, hypoesthesia, and paralysis of the left side of the body. Magnetic resonance imaging revealed an acute cerebral infarction in the right thalamus, and magnetic resonance angiography demonstrated occlusion of the right posterior cerebral artery and dilation of V3 of the left VA. Digital subtraction angiography revealed a left VA dissecting aneurysm at V3 and left VA occlusion at the level of C1-C2 during neck rotation to the right. A dynamic x-ray suggested atlantoaxial joint instability, and three-dimensional computed tomography revealed aplasia of C1 lamina and atlantoaxial rotatory dislocation. BHS with left VA dissecting aneurysm caused by atlantoaxial rotatory dislocation was diagnosed. We performed C1-C2 posterior fusion by the Goel-Harms technique. Stroke did not recur, and computed tomography angiography obtained 8 months postoperatively demonstrated a decrease in the dissecting aneurysm. CONCLUSIONS: To our knowledge, this is the first case of BHS with VA dissecting aneurysm and aplasia of C1 lamina. Based on this case, we suggest that C1-C2 posterior fusion is effective for BHS with VA dissecting aneurysm.

Paradoxical intraoperative embolism in a patient with Eisenmenger syndrome undergoing hip arthroplasty. / Embolismo paradójico intraoperatorio en paciente con síndrome de Eisenmenger sometida a hemiartroplastia de cadera.

Hip arthroplasty is associated with a high incidence of embolic events that, although usually not relevant at a clinical level, may be an important cause of morbidity and mortality in certain situations. Extreme caution should be taken in patients with cardiac defects that favor communication between the pulmonary and systemic circulation, due to their greater risk of complications. We present the case of a 72-year-old patient who suffered a paradoxical embolism during the intervention, with devastating consequences.

Severe Reversible Cerebral Vasoconstriction Syndrome with Large Posterior Cerebral Infarction.

Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and multifocal cerebral vasoconstriction. Cerebral vasoconstriction is reversible, and most cases have good prognosis. However, clinical outcome is possibly severe when it is complicated by stroke, yet detailed reports on such a case are few. We experienced a case of severe reversible cerebral vasoconstriction syndrome in a 32-year-old woman with medical history of preeclampsia 3years prior. She presented with sudden sharp headache followed by altered mental status and vasoconstriction of the bilateral posterior cerebral arteries. She was treated with intravenous and oral calcium channel blockers, edaravone, and glycerol. However, the cerebral infarction in the posterior circulation subsequently remained, and her impaired consciousness did not recover. Furthermore, although imaging findings of vasoconstriction showed improvement a day after the occurrence of symptom, the same vessels showed poor visualization 7 weeks later, which indicated the recurrence of vasoconstriction, without additional symptom due to the fixed infarction. Although most cases of reversible cerebral vasoconstriction syndrome show good prognosis, neurologists must monitor the possibility of worse clinical course and permanent neurological deficit when associated with stroke, such as cerebral infarction. Strict management and treatment are needed in these cases.

Impact of Right-Sided Aneurysm, Rupture Status, and Size of Aneurysm on Perforator Infarction Following Microsurgical Clipping of Posterior Communicating Artery Aneurysms with a Distal Transsylvian Approach.

BACKGROUND: Posterior communicating artery (PCoA) aneurysms are among the most common aneurysms. Because blockage of the PCoA and perforators can cause adverse outcomes, occlusion of these arteries by surgical clipping should be avoided. The impact of factors on PCoA perforator infarction when using a distal transsylvian approach for PCoA aneurysms was examined. METHODS: A total of 183 patients underwent PCoA aneurysm clipping, excluding application of fenestrated clips. Patients were divided into 2 groups: patients with PCoA perforator infarction (infarction group) and patients without infarction (noninfarction group). Multiple factors were analyzed in the 2 groups. RESULTS: Twenty-two of the 183 patients (12.0%) showed perforator infarction, mainly on magnetic resonance imaging evaluation, resulting in permanent deficits in 2 patients (1.1%). The proportion of right-sided operations (86.4% vs. 53.4%; P = 0.005) and surgery for rupture (90.9% vs. 55.9%; P = 0.002) were significantly higher in the infarction group than in the noninfarction group. Aneurysms were significantly larger in the infarction group (8.4 ± 3.8 mm) than in the noninfarction group (6.3 ± 3.0 mm; P = 0.02). Ruptured status (odds ratio [OR], 7.35; P = 0.01), right side (OR, 5.19; P = 0.01), and aneurysm size (OR, 1.18; P = 0.02) remained independent predictors of perforator infarction on multivariate logistic regression analysis. CONCLUSIONS: Ruptured status, right side, and large PCoA aneurysm were independent predictors of PCoA perforator infarction. Symptoms due to PCoA perforating infarction were mostly transient and rarely affected outcomes.

Perioperative Bioccipital Watershed Strokes in Bilateral Fetal Posterior Cerebral Arteries During Spinal Surgery.

BACKGROUND: Vision loss due to cerebral infarction during spinal surgery is less described. Intraoperative hypotension would be a leading cause. Patients with variation of the circle of Willis could be more prone to present stroke in this context, but reports are lacking to sustain the theory. Bilateral occipital watershed ischemic strokes have never been described before. We report the case of a patient with a fetal origin of both posterior cerebral arteries (PCAs), presenting this particular anatomic stroke following lumbar laminectomy surgery for spinal stenosis during which intraoperative hypotension was observed. We discuss how this common anomaly associated with intraoperative hypotension could have promoted this serious complication. CASE DESCRIPTION: A 55-year-old man woke up with cortical blindness after he had undergone lumbar surgery during which a marked decrease in blood pressure had occurred. Magnetic resonance imaging revealed bilateral symmetric infarctions of the occipital lobes in the distal territory of both PCAs and smaller anterior watershed ischemic strokes, suggesting a hemodynamic mechanism. Extended investigations, including conventional angiography, failed to find any cause of stroke but revealed bilateral fetal PCAs supplied by internal carotid arteries only. Two years later, the patient has not recovered and remains severely visually impaired. CONCLUSIONS: The standing hypothesis would be posterior low-flow infarctions resulting from intraoperative hypotension on a variation of the circle of Willis more prone to decrease in cerebral blood flow. Moreover, this case supports the hypothesis of vascular insufficiency due to intraoperative hypotension as cause of stroke during spinal surgery.

Delayed cerebral ischemia associated with reversible cerebral vasoconstriction in a patient with Moyamoya disease with intraventricular hemorrhage: Case report.

We describe a case of cerebral infarctions caused by transient vasoconstrictions in the posterior circulation 2 weeks after intraventricular hemorrhage without subarachnoid hemorrhage in a 35-year-old patient with Moyamoya disease. To our knowledge, this is the first case report where diffuse segmental vasoconstrictions of the basilar and posterior cerebral arteries were recognized after intraventricular hemorrhage in Moyamoya disease. The patient complained of severe and acute-onset headache 14 days after the intraventricular hemorrhage, which had a different character and severity from the one she complained of at the onset of intraventricular hemorrhage. Finally, headache disappeared within 1 month and vasoconstriction resolved in 2 months. Reversible cerebral vasoconstriction syndrome was under consideration for the etiology of her condition because of the "thunderclap" characteristics of the headache and the delayed timing of occurrence of the vasoconstriction. This case report informs and alerts neurologists, neurosurgeons and neuroradiologists who observe and treat patients with Moyamoya disease that vasoconstriction in the posterior circulation may occur after intraventricular hemorrhage in these patients.

Etiology and Risk Factors of Posterior Circulation Infarction Compared with Anterior Circulation Infarction.

BACKGROUND: Many clinicians regard posterior circulation infarction (PCI) as different from anterior circulation infarction (ACI), leading them to apply different treatments. Few studies have validated this practice by directly comparing the etiology and risk factors of PCI and ACI. METHODS: We compared the etiology and risk factors of 2245 consecutive patients with a diagnosis of PCI or ACI confirmed by magnetic resonance imaging in the Chengdu Stroke Registry. Stroke etiology in each patient was classified according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. RESULTS: Our sample included 482 patients (21.5%) with PCI and 1763 (78.5%) with ACI. The most frequent etiology for both infarction types was small-artery occlusion, occurring in 37.6% of patients with PCI and 37.1% of those with ACI. Cardioembolism caused infarction in a significantly smaller proportion of patients with PCI (5.4%) than in patients with ACI (13.3%; odds ratio [OR] = .373; 95% confidence interval [CI], .245-.566). Frequencies of other stroke etiologies were similar between the 2 patient groups. Analysis of risk factor frequencies in the 2 groups showed hypertension to be the most common, occurring in 47.9% of patients in either group. Multivariable analysis identified 2 factors as conferring greater risk of PCI than ACI: male gender (OR = 1.392; 95% CI, 1.085-1.786) and diabetes mellitus (OR = 1.667; 95% CI, 1.275-2.180). The same analysis identified 2 factors as conferring greater risk of ACI: atrial fibrillation (OR = .530; 95% CI, .295-.951) and heart valve disease (OR = .433; 95% CI, .203-.922). Frequencies of other possible risk factors were similar between the 2 groups. CONCLUSIONS: These findings suggest that PCI and ACI are more similar than different in their etiology and risk factors and that the 2 types of infarction should be treated based more on etiology and risk factors than on their posterior or anterior localization.

Aberrant posterior inferior cerebellar artery injury with C1 lateral mass screw placement: a case report and review of the literature.

BACKGROUND CONTEXT: Complications associated with C1 lateral mass screw placement are relatively infrequent. The most commonly feared complications include neural or vascular injury. Although both vertebral artery and internal carotid artery injuries have been discussed in the literature, there have been no reports of posterior inferior cerebellar artery (PICA) injury from C1 lateral mass screw placement. We report a case of patient who had a cerebellar stroke after C1 lateral mass screw placement, secondary to injury of an aberrant PICA. PURPOSE: To describe the normal anatomy of the PICA, the anatomic variations previously reported in the literature, the sequela and symptoms of a patient with PICA injury, and the relevance to C1 lateral mass screw placement. No previous reports of PICA injury with a cerebellar stroke have been reported with C1 lateral mass screw instrumentation. STUDY DESIGN: Case report and literature review. METHODS: The patient underwent an Occiput-C6 posterior instrumentation for a pathologic fracture, secondary to multiple myeloma. In the postoperative period, the patient was found to have dysarthria, imbalance, and dysdiadochokinesia. Urgent computed tomography confirmed well placed C1 lateral mass screws. Magnetic resonance imaging/Magnetic Resonance Angiography showed an infarct in the PICA distribution with an abnormal variant of the PICA coursing extracranially around C1. Neurologic monitoring did not detect the injury intraoperatively. RESULTS: The patient was treated with anticoagulation and he made a reasonable recovery from his stroke. CONCLUSIONS: We report the first case of an aberrant PICA injured during a C1 lateral mass screw placement, resulting in a cerebellar stroke. Consideration should be given to abnormal PICA variation when placing C1 lateral mass screws.

Stroke in young with primary protein--S deficiency.

Stroke in young is a major health problem in developing countries along with CAD, according to various Indian studies its prevalence is 25-34%. Thrombophilic disorders constitute aetiology in 60% cases of stroke of undetermined aetiology. A 20 yrs old young female presented with symptoms of left PCA thrombosis (P2 syndrome), on evaluation--Isolated Protein--S deficiency is noticed. In this case Protein-S deficiency seems to be the only risk factor responsible for stroke.

Factors related to the initial stroke severity of posterior circulation ischemic stroke.

BACKGROUND: Posterior circulation (PC) stroke, which was previously less well known than anterior circulation (AC) stroke, has become more identified due to the development of imaging equipment. Recently, the initial stroke severity assessed by the NIH Stroke Scale (NIHSS) was reported as a useful measure for predicting the outcome of PC as well as AC stroke. The aim of our study was to investigate the factors related to the stroke severity of PC ischemic stroke as assessed by the baseline NIHSS and the predictors of progressive neurological deficit and 3-month outcome. METHODS: All patients with first-time PC stroke (onset ≤ 7 days), admitted for a 5-year period and given a complete evaluation including brain MRI and angiographic studies, were enrolled. Patients were divided into two groups by the baseline NIHSS: moderate-to-severe stroke (MTSS, NIHSS > 5) and mild stroke (MS, NIHSS ≤ 5). Baseline characteristics, symptoms and progression, etiological subtypes, lesion characteristics from imaging, and patient 3-month outcome assessed by the modified Rankin Scale (mRS) were compared between the two groups. RESULTS: Among 604 enrolled patients with PC ischemic stroke, 143 belonged to the MTSS group and 461 to the MS group. In logistic regression analysis, MTSS was independently associated with white blood cell count (odds ratio, OR = 1.00, p = 0.001), high sensitivity C-reactive protein level (OR = 1.23, p = 0.004), dysarthria (OR = 2.59, p = 0.013), weakness (OR = 6.43, p < 0.001), dysphagia (OR = 5.77, p < 0.001) and decreased consciousness (OR = 10.54, p < 0.001). The independent predictors associated with progressive neurological deficit were MTSS (OR = 3.82, p = 0.001), the distal territory classified by lesion location (OR = 0.09, p = 0.004) and dysphagia (OR = 2.38, p = 0.010). The independent predictors associated with a 3-month mRS of 3-6 were MTSS (OR = 7.69, p < 0.001), diplopia (OR = 0.26, p = 0.023), visual field defect (OR = 4.87, p = 0.014), dysphagia (OR = 3.15, p < 0.001) and progressive neurological deficit (OR = 4.27, p < 0.001). CONCLUSIONS: The initial severity categorization of PC ischemic stroke by the NIHSS has provided several distinctions and could help with the prediction of neurological deficit progression and 3-month clinical outcome.

Internal carotid artery stenosis presenting as ipsilateral posterior cerebral artery ischaemic stroke: a lesson to be learnt.

A 71-year-old lady presented with a symptomatic left cerebral occipital lobe infarct. With a history of paroxysmal atrial fibrillation a cardioembolic source was initially postulated. Prior significant bleeding while anticoagulated precluded warfarin therapy. Further investigations revealed a critical left internal carotid stenosis with a persistent fetal origin of the left posterior cerebral artery. She was successfully treated surgically and suffered no further ischaemic events. Physicians encountering posterior circulation stroke should be aware of this potentially treatable important diagnosis.

Neonatal posterior cerebral artery stroke: clinical presentation, MRI findings, and outcome.

AIM: To report the clinical presentation, magnetic resonance imaging (MRI) findings, and follow-up data of newborn infants with perinatal arterial ischemic stroke in the territory of the posterior cerebral artery (PCA). METHOD: Data on 18 newborn infants from three neonatal intensive care units (11 males, seven females) with an MRI-confirmed PCA stroke were analysed and reported. Infants were born at a mean gestational age of 38.7 weeks (SD 3.4) with a mean birthweight of 3244g (SD 850). RESULTS: Fourteen infants presented with clinical seizures. Five of these had associated hypoxic-ischemic encephalopathy, four had hypoglycaemia, and five had neither hypoxic-ischemic encephalopathy nor hypoglycaemia. Subclinical seizures were present in one infant with hypoxic-ischemic encephalopathy and one with meningitis. One preterm infant presented with apnoeas and one had hypoxic-ischemic encephalopathy without seizures. Neurodevelopmental follow-up of 17 children at a median age of 36 months (SD 28, range 12-120mo) showed five with a global delay. Two children with additional injury developed postneonatal epilepsy and one child with extensive injury developed hemiplegia. A visual field defect was observed in nine children (six hemianopia, three quadrantanopia). In the 11 children with a second MRI at 3 months, the asymmetry of the optic radiation correlated with the development of a visual field deficit. INTERPRETATION: Outcome after PCA stroke is fairly good, depending on additional brain injury. Follow-up is required, as subsequent visual field defects are frequently observed. Further research will be needed to clarify the role of hypoglycaemia in perinatal arterial ischemic stroke.

[Stroke and Takotsubo syndrome: a reciprocal relationship]. / Ictus y síndrome de takotsubo: una relación recíproca.

INTRODUCTION: Takotsubo syndrome is a transient stress cardiomyopathy associated with a distinctive left ventricular contraction pattern. It has been described as a cardioembolic source or as a consequence of stroke. Two patients are reported that illustrate the reciprocal relationship between Takotsubo syndrome and stroke and the physiopathological mechanisms implicated are analyzed. CASE REPORTS: Two women aged 70 and 78 years respectively are described. The first one was admitted with electro-cardiogram ST-segment elevation, slight troponin elevation and stroke symptoms. Ecocardiography and cardiac magnetic resonance findings were consistent with Takotsubo syndrome that was the probable source of cardioembolic stroke. The second patient suffered a Takotsubo syndrome 72 hours after a brain infarction involving the insular cortex that was considered the trigger of Takotsubo syndrome. CONCLUSIONS: Takotsubo syndrome and stroke may have a reciprocal etiological relationship that is suggested by the temporal profile between the two processes. Cardiac magnetic resonance may aid in the establishment of the diagnosis of Takotsubo syndrome.