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[Ischemia of the vertebrobasilar territory: mechanisms and practical considerations]
1Servicio de Stroke; Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA. gsaposnik@intramed.net.ar
Insights
Understanding vertebrobasilar ischemia, a complex stroke type, involves recognizing diverse mechanisms and factors influencing patient outcomes. Accurate diagnosis of the stroke cause is crucial for improving prognosis in posterior circulation ischemia.
Area of Science:
- Neurology
- Vascular Neurology
- Epidemiology
Context:
- Vertebrobasilar territory ischemia presents unique diagnostic and therapeutic challenges compared to carotid circulation strokes.
- Posterior circulation strokes, or vertebrobasilar strokes, serve as a model for understanding complex ischemic processes.
- Historical perspectives, anatomical considerations, and epidemiological data are essential for comprehending vertebrobasilar ischemia.
Purpose:
- To review the historical evolution of understanding stroke mechanisms and treatments within the vertebrobasilar territory.
- To describe the various mechanisms underlying ischemic stroke in the posterior circulation.
- To highlight key contributions of researchers in the field of vertebrobasilar ischemia.
Summary:
- Ischemic stroke in the posterior circulation arises from diverse mechanisms including large artery disease, penetrating vessel disease, cardioembolism, and less common causes.
- Transient ischemic attacks (TIAs) in the vertebrobasilar system can be early indicators, necessitating careful diagnosis for effective treatment.
- Accurate identification of the underlying cause of vertebrobasilar stroke is paramount for successful therapeutic interventions.
Impact:
- Prognosis for vertebrobasilar ischemia is influenced by stroke mechanism, occlusion site, thrombus, collateral flow, hemodynamic and hemorreologic factors, neurological status, and treatment timing.
- A precise diagnosis of the stroke mechanism significantly enhances the potential for a better patient outcome.
- Advances in diagnostic and therapeutic strategies for cerebrovascular diseases continue to evolve, particularly for complex cases like vertebrobasilar ischemia.
Objective:
We first review historic, anatomic, and epidemiological aspects involving the vertebrobasilar territory ischemia. We describe the development of ideas regarding the stroke mechanisms and treatment in the posterior circulation. Key authors and their contributions are also mentioned.
Development:
Several new diagnostic and therapeutic strategies have emerged during the last few decades in cerebrovascular disease. The comprehension of the ischemic stroke in the posterior circulation is more difficult than carotid circulation. Thus, vertebrobasilar stroke represents a microcosm. Several mechanisms may explain the ischemic process (large artery disease, penetrating vessel disease, cardioembolism, unusual causes of stroke, and combined or undetermined causes). One of the most common is large artery atherosclerosis. Transient ischemic attacks, usually stereotyped, may be the clue for the earliest recognition. Correct diagnosis may improve the chance of effective therapy. Some practical considerations may help to identify the underlying cause of the stroke.
Conclusions:
The prognosis in patients with vertebrobasilar ischemia depends on: a) the mechanism of the stroke, b) site of the vessel occlusion, c) thrombus propagation, d) collateral circulation, e) hemodynamic (hypertension, cardiac output, etc.), and hemorreologic factors (viscosity, hypercoagulable state, etc.), f) neurologic status, g) time to treatment. The accurate the diagnosis of the mechanism, the better the prognosis.