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Abstract
Background and Objectives To perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.
Methods Review of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.
Results PCI accounts for 15%–20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%–60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.
Discussion PCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.
Glossary
- AC=
- anterior circulation;
- ACI=
- anterior circulation ischemia;
- AHA=
- American Heart Association;
- AICA=
- anterior inferior cerebellar artery;
- AIS=
- acute ischemic stroke;
- AT=
- antithrombotic treatment;
- BA=
- basilar artery;
- BAO=
- basilar artery occlusion;
- CI=
- confidence interval;
- CTA=
- CT angiography;
- CTP=
- CT perfusion;
- EVT=
- endovascular thrombectomy;
- IA-PT=
- intraarterial pharmaceutical thrombolysis;
- IAT=
- intra-arterial therapy;
- ICA=
- internal carotid artery;
- ICAD=
- intracranial atherosclerosis disease;
- ICH=
- intracerebral hemorrhage;
- IVT=
- IV thrombolysis;
- LVO=
- large vessel occlusion;
- mRS=
- modified Rankin Scale;
- MT=
- mechanical thrombectomy;
- NIHSS=
- National Institutes of Health Stroke Scale;
- OR=
- odds ratio;
- PC=
- posterior circulation;
- pc-ASPECTS=
- Alberta Stroke Program Early CT Score for the posterior circulation;
- PCA=
- posterior cerebral artery;
- PCI=
- posterior circulation ischemia;
- PICA=
- posterior inferior cerebellar artery;
- PPV=
- positive predictive value;
- RCT=
- randomized controlled trial;
- RR=
- risk ratio;
- SA=
- subclavian artery;
- SAH=
- subarachnoid hemorrhage;
- SCA=
- superior cerebellar artery;
- sICH=
- symptomatic intracerebral hemorrhage;
- SNIS=
- Society of Neurointerventional Surgery;
- VA=
- vertebral artery;
- VBD=
- vertebrobasilar dolichoectasia
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received November 20, 2020.
- Accepted in final form April 29, 2021.
- © 2021 American Academy of Neurology
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