Clinical characteristics, Risk factors, and outcomes of Posterior circulation stroke: A retrospective study between younger and older adults in Saudi Arabia.

INTRODUCTION: Posterior circulation stroke (PCS) may be less prevalent than its anterior counterpart but contributes to substantial morbidity and mortality. The aim was to characterize PCS's demographics, clinical presentation, management, and outcomes between younger and older adults in Saudi Arabia. METHODS: This retrospective cohort study was conducted at two tertiary medical centers in Saudi Arabia between March 2016 and December 2020. All patients who presented with symptoms of posterior circulation stroke and had positive brain imaging were included. RESULTS: The study involved 160 posterior circulation stroke patients, stratified into two age groups: 71 patients aged 18-59 years and 89 patients aged 60 years and above. The mean age of the entire cohort was 60.9 years, and 77 % were males. Hypertension was more prevalent in the older age group (88 % vs. 69 %, p=0.005), and smoking was significantly higher among younger patients (38 % vs. 15 %; p=0.0009). Only 22.4 % received thrombolysis and/or thrombectomy. Most strokes involved the posterior cerebral artery (45.6 %). Large artery atherosclerosis was the most common subtype. At discharge, younger patients had higher NIHSS compared to older patients. CONCLUSION: Our investigation of 160 PCS patients in Saudi Arabia uncovers notable trends: a mere 22.4 % received thrombolysis and/or thrombectomy and a significant prevalence of posterior cerebral artery involvement due to large artery atherosclerosis. The study further reveals younger patients disproportionately had severe outcomes. Highlighting the need for improved stroke care and heightened awareness, this research contributes vital data to an underexplored domain, urging further study to optimize care and understand PCS dynamics in Saudi Arabia.

Presenting Symptoms and Imaging Features of Posterior Cerebral Artery Stroke Causing Homonymous Hemianopia.

BACKGROUND: Posterior cerebral artery (PCA) stroke is a common cause of homonymous hemianopia and other neurologic deficits associated with more proximal ischemia in the vertebrobasilar circuit. Localization of the process can be challenging unless the symptom complex is well recognized, yet early diagnosis is critical to forestall dangerous driving and repeated stroke. We undertook this study to provide additional detail about the presenting symptoms and signs and their correlation with imaging abnormalities and stroke etiology. METHODS: Retrospective study of medical records of patients presenting to a single tertiary care academic center between 2009 and 2020 with homonymous hemianopia from PCA stroke. We excerpted data on symptoms, visual and neurologic signs, incident medical procedures and diagnoses, and imaging features. We determined stroke etiology using the Causative Classification Stroke system. RESULTS: In a cohort of 85 patients, 90% of strokes occurred without preceding symptoms. But in retrospect, 10% of strokes did have warning symptoms. In 20% of patients, strokes followed within 72 hours of a medical or surgical procedure or newly identified medical condition. In the subgroups of patients whose records contained a description of visual symptoms, 87% reported the visual sensation as negative, and 66% realized that it was located in a hemifield in both eyes. Concurrent nonvisual symptoms were present in 43% of patients, consisting commonly of numbness, tingling, and new headache. Infarction located outside the visual cortex affected primarily the temporal lobe, thalamus, and cerebellum, reflecting the widespread nature of ischemia. Nonvisual clinical manifestations and arterial cutoffs on imaging were associated with thalamic infarction, but the clinical features and location of the infarction did not correlate with the etiology of the stroke. CONCLUSIONS: In this cohort, clinical localization of the stroke was aided by the fact that many patients could lateralize their visual symptoms and had nonvisual symptoms suggestive of ischemia affecting the proximal vertebrobasilar circuit. Numbness and tingling were strongly linked to concurrent thalamic infarction. Clinical features and infarct location were not associated with the etiology of the stroke.

Demographics, Risk Factors, and Etiology of Posterior Cerebral Artery Stroke Causing Homonymous Hemianopia.

BACKGROUND: Posterior cerebral artery (PCA) strokes account for up to 10% of all ischemic strokes, often presenting with homonymous hemianopia. The proportion of these strokes attributed to various etiologies varies widely in previously published studies, owing largely to differing patient populations, definitions of stroke pathogenesis, and vascular territories involved. The Causative Classification System (CCS), an automated version of the Stop Stroke Study (SSS) Trial of Org 10,172 in Acute Stroke Treatment (TOAST) system, allows for a more rigorous assignment of stroke etiology. METHODS: We excerpted clinical and imaging data on 85 patients who had PCA stroke with homonymous hemianopia examined at the University of Michigan. We compared the stroke risk factor profile of our PCA cohort with that of 135 patients with stroke in the distribution of the internal carotid artery (ICA) and middle cerebral artery (MCA) in an unpublished University of Michigan registry. We applied the CCS web-based calculator to our PCA cohort to determine stroke etiology. RESULTS: In our PCA cohort, 80.0% had at least 2 conventional stroke risk factors and 30.6% had 4 risk factors, most commonly systemic hypertension. The risk factor profile of our PCA cohort resembled that of our ICA/MCA cohort except that the mean age of our PCA cohort was more than a decade younger and had a significantly lower frequency of atrial fibrillation (AF) than our ICA/MCA cohort. In nearly half of the patients with AF in our PCA cohort, AF was diagnosed after the stroke. Among stroke etiologies in our PCA cohort, 40.0% were of undetermined cause, 30.6% were from cardioaortic embolism, 17.6% were from other determined causes, and only 11.8% were from supra-aortic large artery atherosclerosis. Strokes after endovascular or surgical interventions were prominent among other determined causes. CONCLUSIONS: Most patients in our PCA cohort had multiple conventional stroke risk factors, a finding not previously documented. Mean age at stroke onset and AF frequency were lower than in our ICA/MCA cohort, in agreement with previous studies. As some other studies have found, nearly 1/3 of strokes were attributed to cardioaortic embolism. Within that group, AF was often a poststroke diagnosis, a finding not previously highlighted. Compared with earlier studies, a relatively high portion of strokes were of undetermined etiology and of other determined etiologies, including stroke after endovascular or surgical interventions. Supra-aortic large artery atherosclerosis was a relatively uncommon explanation for stroke.

Occipito-temporal infarction manifesting as isolated visual perceptual abnormalities: A rare case of posterior cerebral artery stroke.

Ischemic stroke in the Posterior Cerebral Artery (PCA) territory is an uncommon entity. Majority present with visual field defects while isolated visual perceptual abnormalities are an exceptional manifestation. About 60 year old hypertensive patient presented with vague symptoms of blurring of vision and palinopsia. Defective color vision was recorded in superior quadrants. Perimetry revealed bilateral congruous left superior quadrantanopia. Magnetic Resonance Imaging (MRI) disclosed right PCA infarct involving occipito-temporal region. This case highlights a rare presentation of PCA stroke with palinopsia and cerebral dyschromatopsia. Perimetric examination coupled with urgent neuroimaging helps the clinician in prompt diagnosis of neurological event causing unexplained visual phenomena.

Accuracy of Visual Fields in Localizing MRI Lesions in Posterior Cerebral Artery Infarction.

BACKGROUND: The representation of the visual field in visual cortex was established over a century ago by correlating perimetric defects with the estimated location of war wounds. The availability of high-definition MRI offers the possibility of more precise correlation. METHODS: Homonymous hemianopias disclosed on automated visual fields (HVFs) were drawn from an electronic medical record search from 2009 to 2020 at the Michigan Medicine, a tertiary care academic medical center. The patterns of the visual field defects (VFDs) were interpreted by a consensus of 2 authors. The VFDs were correlated with the location of MRI lesions in 92 patients with posterior cerebral artery (PCA) domain ischemic strokes, as determined by the neuroradiologist author, who was masked as to the VFDs. RESULTS: Among the 77 VFDs confined to 1 hemifield, 74 (96%) correctly predicted the side of the visual cortex lesion. In 3 cases, the MRI lesion in the opposite cerebral hemisphere was not foretold. Among the 15 VFDs present in both hemifields, 5 (33.3%) overestimated the MRI lesions, which were evident in only 1 hemisphere. Among the 30 VFDs confined to 1 quadrant, 29 (97%) correctly predicted the lesioned visual cortex quadrant. However, 14 VFDs failed to predict MRI lesions present in both superior and inferior visual cortex quadrants on the same side. Those unpredicted lesions mostly had subtle or indistinct signal abnormalities or were confined to anterior visual cortex, an area that is inaccessible with the HVF test protocol used in this study. CONCLUSION: In this study of PCA ischemic stroke, VFDs limited to 1 hemifield were accurate in locating the side and quadrant of the MRI visual cortex lesions. However, the quadrantic VFDs sometimes failed to predict that the lesions involved both the superior and inferior quadrants on the same side, largely because those lesions had subtle imaging features that defied accurate radiologic assessment or were out of the reach of the visual field test protocol.

Correlation of Macular Sparing and Homonymous Paracentral Scotomas With MRI Lesions in Posterior Cerebral Artery Infarction.

BACKGROUND: The concepts of the representation of visual field in primary visual cortex are based on studies of war wounds and correlations with brain imaging in small cohorts. Because of the difficulty of judging brain lesion extent and the small number of studied patients, there is lingering controversy as to whether the central 15° of visual field are mapped onto the posterior 25% of primary visual cortex or onto a larger area. To improve the delineation of MRI lesion extent, we have studied only patients with posterior cerebral artery (PCA) ischemic strokes. METHODS: We accrued a cohort of 92 patients with PCA strokes from an electronic medical records search between 2009 and 2020 at a single tertiary care academic institution. Patients had reliable static perimetry demonstrating homonymous hemianopias and high-definition reviewable brain imaging. We divided the primary visual cortex on the MRI T1 sagittal sequence into 8 equal segments in right and left cerebral hemispheres and located lesions according to the segments they occupied. We correlated lesion locations with 3 visual field defects (VFDs): macular-sparing homonymous quadrantanopias, macular-splitting homonymous quadrantanopias, and homonymous paracentral scotomas. RESULTS: Among 25 cases with macular sparing, 13 had lesion-sparing confined to the posterior 25% of visual cortex. Among 6 cases with homonymous paracentral scotomas, 2 had lesions confined to the posterior 25% of visual cortex. Macular-splitting quadrantanopia did not occur in any patients with lesions confined to the posterior 25% of visual cortex, but did occur in 3 patients with lesions confined to the posterior 50% of visual cortex. These phenomena would not be expected if the central 15° of visual field were mapped onto a region extending beyond the posterior 25% of visual cortex. In patients with PCA strokes that involved the retrogeniculate visual pathway proximal to visual cortex, the visual cortex lesions were often less extensive than predicted by the VFDs, perhaps because of widespread damage to axons before they reached their destination in visual cortex. CONCLUSIONS: These results support the concept that the central 15° of the visual field are represented in the posterior 25% of visual cortex. Although this study contributes a larger cohort of patients with better-defined lesion borders than in past reports, its conclusions must be tempered by the variability of patient attention during visual field testing, the subjectivity in the interpretation of the defect patterns, and the difficulty in judging MRI lesion extent even on diffusion-weighted and precontrast T1 sagittal sequences.

Infarto cerebeloso bilateral agudo en territorio de la arteria cerebelosa posterior inferior: reporte de caso / Acute bilateral cerebellar infarction in territory of the posterior inferior cerebellar artery: a case report

Antecedentes: Los infartos cerebelosos suponen una entidad rara con una incidencia baja del total de ictus isquémicos. El territorio más prevalente de los infartos cerebelosos son los de la arteria cerebelosa posterior inferior (PICA). Cuando los infartos se limitan al cerebelo, los pacientes típicamente experimentan síntomas no específicos, esto hace considerar otros diagnósticos de forma errónea. Descripción del caso clínico: paciente femenina de 54 años, con antecedente de hipertensión arterial, quien presentaba cefalea insidiosa y progresiva acompañado de vértigo, alteración en la marcha y deterioro progresivo del estado de conciencia. Se realizó imagen de Resonancia Magnética Cerebral (IRM), la cual reveló zonas hiper intensas bilaterales en región cerebelosa que delimitaban territorio vascular de la arteria cerebelosa posterior inferior además dilatación moderada del sistema ventricular. Fue intervenida quirúrgicamente, realizándose craniectomía suboccipital descompresiva; posterior a la cirugía presentó mejoría clínica. Conclusiones: El ictus isquémico cerebeloso bilateral es una forma infrecuente de ictus y su presentación clínica es muy diversa. El desarrollo de las neuroimágenes, juegan un papel importante para ayudar a los médicos a seleccionar el tratamiento adecuado. Alrededor de la mitad de los pacientes con infartos cerebelosos que presentan deterioro neurológico progresivo y son tratados con craniectomía suboccipital descompresiva tienen buenos resultados. El pilar fundamental de este caso fue el hacer un diagnóstico temprano de esta entidad, ya que permitió prevenir las posibles complicaciones graves asociadas al infarto cerebeloso, las cuales ocurren durante la primera semana del ictus y, por lo tanto, asegurar un pronóstico favorable para el paciente...(AU)

Posterior cerebral artery stroke by reverse flow embolism in thoracic outlet syndrome - a case report.

BACKGROUND: Arterial thoracic outlet syndrome is a rare condition characterized by a subclavian artery pathology associated with a bone abnormality. It is rarely associated with thromboembolic stroke. The mechanism of cerebral embolism associated with thoracic outlet syndrome have rarely been demonstrated. We present here a fully studied case with a high probability of reverse flow embolism. CASE PRESENTATION: A 24-year-old man with a known arterial thoracic outlet syndrome presented with a right cerebral posterior artery brain infarction. An ultrasound examination depicted the compression of the right subclavian artery in the scalene defile with a post stenotic aneurysm and the presence of a floating thrombus in this aneurysm. There was a reverse flow during diastole in this aneurysm. Anticoagulation was carried out with the disappearance of the floating thrombus with no new clinical or brain MRI event. Corrective surgery of this thoracic outlet syndrome was performed one month after stroke. CONCLUSION: Very few cases of stroke in arterial thoracic outlet syndrome have been described with thorough dynamic vascular imaging. To our knowledge, this is the fourth reported case that advocates for a reverse flow embolism mechanism in stroke associated with thoracic outlet syndrome, and the first to realize an extensive ultrasound and doppler workup.

Diagnostic value of eye movement and vestibular function tests in patients with posterior circulation infarction.

OBJECTIVE: To evaluate the diagnostic value of eye movements and vestibular function tests in PCI patients. METHODS: Thirty-eight PCI patients and 31 patients with unilateral vestibular neuritis (UVN) were enrolled and underwent eye movement tests and vestibular function tests (spontaneous nystagmus [SN], head-shaking nystagmus [HSN]). RESULTS: The rates of eye movement abnormality were 78.9% and 41.9% in PCI and UVN patients, respectively. The positive rate of SN and HSN were, respectively, 41.2% and 43.8% in cerebellar infarction patients, 33.3% and 66.7% in medullary infarction patients, and 100.0% and 86.2% in UVN patients. The horizontal direction of SN and HSN coincided with the affected side in cerebellar infarction patients, and the healthy side in UVN patients, which coincided with the healthy side and the affected side, respectively in medullary infarction patients. The horizontal direction of HSN was bidirectional nystagmus in 16.0% (4/25) of UVN patients. CONCLUSIONS AND SIGNIFICANCE: Eye movement and vestibular function tests contribute to the early diagnosis of PCI. The horizontal direction of SN and HSN are consistently toward the affected side in cerebellar infarction patients and the healthy side in UVN patients, in contrast to medullary infarction patients, and deserve further investigations.

Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke.

Background and Purpose- The strong evidence of endovascular therapy in acute ischemic stroke patients with large vessel occlusion (LVO) is revealed. Such patients are required to direct transport to the hospital capable of endovascular therapy. There are several prehospital scales available for paramedics to predict LVO. However, they are time consuming, and several of them include factors caused by other types than LVO. Therefore, we need a fast, simple, and reliable prehospital scale for LVO. Methods- We developed a new prehospital stroke scale, emergent large vessel occlusion (ELVO) screen, for paramedics to predict LVO. The study was prospectively performed by multistroke centers. When paramedics referred to stroke center to accept suspected stroke patients, we obtain the following information over the telephone. ELVO screen was designed focusing on cortical symptoms: 1 observation; presence of eye deviation and 2 questions; paramedics show glasses, what is this? and paramedics show 4 fingers, how many fingers are there? If the presence of eye deviation or ≥1 of the 2 items were incorrect, ELVO screen was identified as positive. We evaluated between results of ELVO screen and presence of LVO on magnetic resonance angiography at hospital arrival. Results- A total of 413 patients (age, 74±13 years; men, 234 [57%]) were enrolled. Diagnosis was ischemic stroke, 271 (66%); brain hemorrhage 73 (18%); subarachnoid hemorrhage, 7 (2%); and not stroke, 62 (15%). One hundred fourteen patients had LVO (internal carotid artery, 33 [29%]; M1, 52 [46%]; M2, 21 [18%]; basilar artery, 5 [4%]; P1, 3 [3%]). Sensitively, specificity, positive predictive value, negative predictive value, and accuracy for ELVO screen to predict LVO were 85%, 72%, 54%, 93% and 76%, respectively. Among 233 patients with negative ELVO screen, only 17 (7%) had LVO, which indicated to be an ideal scale to avoid missing endovascular therapy. Conclusions- The ELVO screen is a simple, fast, and reliable prehospital scale for paramedics to identify stroke patients with LVO for whom endovascular therapy is an effective treatment.

A Posterior Circulation Ischemia Risk Score System to Assist the Diagnosis of Dizziness.

BACKGROUND: We aimed to establish a risk score system without radio-image examination, which could help clinicians to differentiate patients with vertigo and posterior circulation ischemia (PCI) rapidly from the other dizzy patients. METHODS: We analyzed 304 patients with vertigo (50% PCI). The attributes with more significant contributions were selected as the risk factors for the PCI risk score system, and every one of them was assigned a value according to their respective odds ratio values. We also compared the respective receiver operating characteristic curves of the 3 diagnostic methods (PCI score system, ABCD2, and Essen score systems) to evaluate their prediction effectiveness. RESULTS: Nine risk factors were ultimately selected for PCI score system, including high blood pressure (1'), diabetes mellitus (1'), ischemic stroke (1'), rotating and rocking (-1'), difficulty in speech (5'), tinnitus (-5'), limb and sensory deficit (5'), gait ataxia (1'), and limb ataxia (5'). According to their respective PCI risk scores, the patients were divided into 3 subgroups: low risk (≤0', risk <37.4%), medium risk (1'-5'), and high risk (≥6', risk >95.0%). When 0' was selected as a cutoff point for differentiating the patients with PCI from patients without PCI, the sensitivity was 94.1%, with a specificity of 41.4%. The areas under the receiver operator curve value of PCI score system was .82 (P = .000), much higher than the areas under the receiver operator curve value of ABCD2 (.69, P = .000) and that of the Essen system (.67, P = .000) CONCLUSION: The PCI score system could help clinicians to differentiate patients with vertigo and PCI rapidly from the other dizzy patients.

Icatibant as a Potential Treatment of Life-Threatening Alteplase-Induced Angioedema.

Severe orolingual angioedema is a life-threatening complication of alteplase treatment for acute ischemic stroke that occurs during alteplase infusion or in the first 2 hours afterward. Currently, there are no proven therapies, although glucocorticoids, antihistamines, and adrenaline are sometimes used. Intubation is required if significant airway compromise supervenes. The incidence is .2%-5.1%, and risk factors include treatment with angiotensin-converting enzyme inhibitors and total insular infarcts. Here we report a case of alteplase-induced severe angioedema, which resolved briskly following icatibant treatment.

High Incidence of Atrial Fibrillation After Embolic Stroke of Undetermined Source in Posterior Cerebral Artery Territory.

BACKGROUND: Subclinical atrial fibrillation is one possible cause of embolic stroke of undetermined source (ESUS). It remains to be elucidated if a specific infarction site has a predictive value for detecting subclinical atrial fibrillation. We aimed to investigate the predictive value of infarction site in patients with ESUS for the detection of atrial tachyarrhythmia (AT) using an insertable cardiac monitor. METHODS AND RESULTS: Consecutive 146 patients (84 men; aged 62±12 years) underwent insertable cardiac monitor implantation after diagnosis of ESUS. The detection of AT >30 seconds was evaluated. The ESUS infarction sites were categorized into internal carotid artery and vertebral artery (VA) territories, with ophthalmic artery, anterior cerebral artery, and middle cerebral artery as internal carotid artery subterritories, and posterior cerebral artery and other vertebrobasilar arteries as VA subterritories. During a median follow-up of 387 days, AT was detected in 33 patients (23%). Subclinical AT detection was significantly more frequent after VA territorial infarction opposed to internal carotid artery infarction (20/57 [35%] versus 13/89 [15%]; P=0.0039). Kaplan-Meier analysis demonstrated a significantly higher AT detection rate after VA infarction (log-rank, P=0.0076). Regression analysis revealed that VA territorial infarction, and particularly posterior cerebral artery area infarction, was an independent predictor of AT detection. CONCLUSIONS: Patients with ESUS in the posterior cerebral artery territory had a higher rate of subclinical AT detection than those with other infarct localizations. Our data suggest that the possible usefulness of ESUS site to identify candidates for direct oral anticoagulation should be confirmed in future research.

Difficulties in the Diagnosis and Management of Paediatric Posterior Circulation Stroke.

We present two children with posterior circulation stroke (PCS) highlighting the wide spectrum of presentation, the need for complete radiological assessment, and the relatively high recurrence risk.

Posterior versus Anterior Circulation Stroke in Young Adults: A Comparative Study of Stroke Aetiologies and Risk Factors in Stroke among Young Fabry Patients (sifap1).

BACKGROUND: Although 20-30% of all strokes occur in the posterior circulation, few studies have explored the characteristics of patients with strokes in the posterior compared to the anterior circulation so far. Especially data on young patients is missing. METHODS: In this secondary analysis of data of the prospective multi-centre European sifap1 study that investigated stroke and transient ischemic attack (TIA) patients aged 18-55 years, we compared vascular risk factors, stroke aetiology, presence of white matter hyperintensities (WMH) and cerebral microbleeds (CMB) between patients with ischaemic posterior circulation stroke (PCS) and those having suffered from anterior circulation stroke (ACS) based on cerebral MRI. RESULTS: We diagnosed PCS in 612 patients (29.1%, 407 men, 205 women) and ACS in 1,489 patients (70.9%). Their age (median 46 vs. 47 years, p = 0.205) and stroke severity (modified Rankin Scale: both 2, p = 0.375, Barthel Index 90 vs. 85, p = 0.412) were similar. PCS was found to be more frequent among the male gender (66.5 vs. 60.1% with ACS, p = 0.003). Vertebral artery (VA) dissection was more often the cause of PCS (16.8%) than was carotid artery dissection of ACS (7.9%, p < 0.001). Likewise, small vessel disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] = 3, PCS: 14.7%, ACS: 11.8%) and stroke of other determined aetiology (TOAST = 4, PCS: 24.5%, ACS: 16.0%) were more frequent in those with PCS. Furthermore, patent foramen ovale (PFO; PCS: 31.1%, ACS: 25.4%, p = 0.029) was more often detected in patients with PCS. In contrast, large-artery atherosclerosis (TOAST = 1, PCS: 15.4%, ACS: 22.2%) and cardio-embolic stroke (TOAST = 2, PCS: 15.6%, ACS: 18.0%) were less frequent in those with PCS (p < 0.001) as were preceding cerebrovascular events (10.1 vs. 14.1%, p = 0.014), TIA (4.8 vs. 7.7%, p = 0.016) and smoking (53.2 vs. 61.0%, p = 0.001). The presence, extent, and location of WMH and CMB did not differ between the 2 groups. CONCLUSIONS: Our data suggested a different pattern of aetiology and risk factors in young patients with PCS compared to those with ACS. These findings especially call for a higher awareness of VA dissection and potentially for more weight of a PFO as a risk factor in young patients with PCS. Clinical trial registration-URL: http://www.clinicaltrials.gov; NCT00414583.

e-NIHSS: an Expanded National Institutes of Health Stroke Scale Weighted for Anterior and Posterior Circulation Strokes.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most widespread clinical scale used in patients presenting with acute stroke. The merits of the NIHSS include simplicity, quickness, and agreement between clinicians. The clinical evaluation on posterior circulation stroke remains still a limit of NIHSS. METHODS: We assessed the application of a new version of NIHSS, the e-NIHSS (expanded NIHSS), adding specific elements in existing items to explore signs/symptoms of a posterior circulation stroke. A total of 22 consecutive patients with suspected vertebrobasilar stroke were compared with 25 patients with anterior circulation stroke using NIHSS and e-NIHSS. RESULTS: We compared the NIHSS and e-NIHSS scores obtained by the 2 examiners, in patients with posterior circulation infarct (POCI), using the Wilcoxon test. Patients with POCI evaluated with e-NIHSS had an average of 2 points higher than patients evaluated with classical NIHSS. The difference was statistically significant (P < .05), weighted by the new expanded items. CONCLUSIONS: The NIHSS is a practical scale model, with high reproducibility between trained, different examiners, focused on posterior circulation strokes, with the same total score and number of items of the existing NIHSS. The e-NHISS could improve the sensitivity of NIHSS in posterior circulation stroke and could have an impact on clinical trials, as well as on outcomes. Further studies are needed to investigate a larger number of patients and the correlation between the e-NIHSS score and neuroimaging findings.

Lateral Thalamic Infarction and the Vascular Geometry of the Posterior Cerebral Artery.

BACKGROUND: The geometric properties of the parental artery affect the development of local atherosclerosis and perforator infarction. In this study, we aimed at investigating the association between vascular geometry of the posterior cerebral artery (PCA) and the development of isolated lateral thalamic infarction (LTI), the most frequent type of thalamic infarction. METHODS: The geometric properties of the corresponding PCA in LTI patients were assessed and they include the diameters of the distal basilar artery (BA) and proximal PCA, distal BA - PCA angle, first PCA angle (angle between P1 and P2), and the presence of the posterior communicating artery (Pcom). These parameters obtained from the ipsilesional PCA were compared with the contralesional PCA and the corresponding PCA in age- and sex-matched controls. RESULTS: Forty-five LTI patients were enrolled. The ipsilesional PCA in LTI patients demonstrated a greater ipsilesional P1 - P2 angle (81.4 ± 22.6 vs. 71.3 ± 23.2°, respectively; p = 0.04) and a higher prevalence of Pcom (42.2 vs. 13.3%; p = 0.002) when compared to control subjects. In comparison with the contralesional PCA, ipsilesional PCA demonstrated a smaller diameter, larger angle between P1 and P2 segment, and a higher prevalence of Pcom. The presence of hyperlipidemia (OR 3.548 (1.283-9.811); p = 0.02) and Pcom (OR 3.507 (1.104-11.135); p = 0.03) was a factor that was independently associated with LTI. CONCLUSIONS: Local hemodynamics in the PCA may be influenced by the P1 - P2 angle and the presence of Pcom, which are associated with the development of LTI.

Sectoral analysis of the retinal nerve fiber layer thinning and its association with visual field loss in homonymous hemianopia caused by post-geniculate lesions using spectral-domain optical coherence tomography.

PURPOSE: To report a sectoral analysis of circumpapillary retinal nerve fiber layer (cpRNFL) thinning and its association with visual field loss using spectral-domain optical coherence tomography (SD-OCT) in patients with homonymous hemianopia following acquired post-geniculate visual pathway damage. PATIENTS AND METHODS: Seven patients with homonymous hemianopia due to unilateral acquired post-geniculate visual pathway lesions were studied. The average duration from the onset of brain lesions to the initial visit was 49.8 months. Forty-nine normal control subjects without visual field defects, as confirmed using a Humphrey visual field analyzer, were also enrolled. Measurement of the cpRNFL thickness was performed at the initial visit and 24 months using SD-OCT (RTVue-100® OCT). The cpRNFL thickness was divided into eight sectors (superior temporal: ST, temporal upper: TU, temporal lower: TI, inferior temporal: IT, inferior nasal: IN, nasal lower: NL, nasal upper: NU, superior nasal: SN). The eye on the same side as the occipital lobe lesions was defined as the ipsilateral eye, and the eye on the opposite side was defined as the contralateral eye. RESULTS: The average cpRNFL thickness in the homonymous hemianopic eyes was significantly reduced as compared with that seen in the normal controls, except for the ipsilateral eyes at the initial visit. Four of the eight sectors of the cpRNFL thickness in the homonymous hemianopic eyes were significantly reduced compared with that noted in the normal controls. In the ipsilateral eyes, the cpRNFL thickness in the ST, TU, TL, and IT sectors was significantly reduced at both the initial visit and 24 months. In the contralateral eyes, the cpRNFL thickness in the TU, TL, IT, and SN sectors was significantly reduced at both the initial visit and 24 months. The reduction of the quadrantic cpRNFL thickness significantly correlated with some of the visual field parameters, in accordance with the structure-function relationship. In the contralateral eyes, the T and I quadrant cpRNFL thickness correlated with the mean deviation and hemianopic field total deviation at 24 months. In the ipsilateral eyes, the S, T, and I quadrant cpRNFL thickness correlated with mean deviation. However, there were no correlations between the cpRNFL thickness and visual field parameters at the initial visit. CONCLUSIONS: A reduction of the cpRNFL thickness corresponding to the hemianopic visual field loss due to acquired post-geniculate visual pathway lesions was detected using SD-OCT, and the change was more evident at 24 months than at the initial visit. The latter finding suggests that this change is, at least partially, caused by transsynaptic retrograde degeneration.

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.