Related Experiment Video
Updated: Aug 13, 2026
Integrated Photoacoustic, Ultrasound, and Angiographic Tomography (PAUSAT) for NonInvasive Whole-Brain Imaging of Ischemic Stroke
Published on: June 2, 2023
ASFNR Clinical State-of-Practice: Neuroimaging in Posterior Circulation Large Vessel Occlusion Stroke
Aakanksha Sriwastwa1, Dhairya A Lakhani2, Hamza A Salim2
1From the Department of Radiology (A.S., A.S.V.), College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA; Department of Radiology (D.A.L.), Division of Neuroradiology,West Virginia University, Morgantown,West Virginia, USA; Department of Neuroradiology (H.A.S.), The University of Texas MD Anderson Center, Houston, Texas, USA; Department of Radiology (D.W.), Rhode Island Hospital, Brown University Health, Providence, Rhode Island, USA; Department of Radiology (M.G., V.S.Y.), Division of Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurology (S.M.), University of Maryland Medical Center, Baltimore, Maryland, USA; Stanford Stroke Center (A.G.), Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA; Department of Radiology, Neuroendovascular Program (T.D.F.), University Medical Center Münster, Münster, Germany; Department of Interventional Neuroradiology (G.W.A., J.J.H.), Stanford Medical Center, Palo Alto, California; Department of Radiology (G.V.S.), University of Michigan, Ann Arbor, USA; Department of Radiology (M.M.-B.), University of Alabama at Birmingham, Birmingham, USA; Department of Radiology (J.W.A.), Indiana University School of Medicine, Indianapolis, USA and Department of Radiology (R.J.), New York University Grossman School of Medicine, New York, USA. sriwasaa@ucmail.uc.edu.
Background:
Posterior circulation (PC) large vessel occlusions (PC-LVO) include occlusions of vertebral arteries, basilar artery and P1 segment of posterior cerebral artery, although the latter is variably classified as a medium vessel occlusion in some studies and clinical trials. PC-LVOs account for a substantial proportion of PC strokes. PC-LVO remains challenging to diagnose due to nonspecific symptoms and limited sensitivity of CT for posterior fossa ischemic changes. However, PC-LVO is associated with substantial disability and mortality, particularly with basilar artery occlusion (BAO). Recent randomized trials demonstrate a clear benefit of endovascular thrombectomy (EVT) for BAO up to 24 hours in selected patients, shifting treatment paradigms toward imaging-guided selection.
Methods:
A working group comprising select members of the Executive Committee and other members of the American Society of Functional Neuroradiology convened to develop a clinical State-of-Practice document on neuroimaging in acute PC-LVO stroke. The aim of this document is to provide a concise, practical, and evidence-informed imaging framework for the diagnosis, triage, and prognostication of patients with PC-LVO stroke in everyday neuroradiology practice.
Key Points:
A multimodal imaging approach is necessary for PC-LVO stroke detection. NCCT is relatively insensitive for ischemia detection but remains essential for excluding hemorrhage, while CTA serves as the diagnostic cornerstone for identifying PC-LVO. CT perfusion may provide additional information, although its sensitivity in the posterior fossa is limited. DWI-MRI remains the reference standard, despite the occurrence of early false negatives and the limited reliability of DWI-FLAIR mismatch in posterior circulation stroke. Imaging biomarkers, including PC-ASPECTS and brainstem infarct scores, are important for patient selection and outcome prediction.
