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Proximal intracranial territory posterior circulation infarcts in the New England Medical Center Posterior
K J Graf1, M S Pessin, L D DeWitt
1Städtische Kliniken Kassel, Germany.
Insights
Posterior circulation ischemia in the proximal territory affects many patients, with cerebellar and medullary infarcts being common. Embolism is a frequent cause, but outcomes are favorable for most survivors.
Area of Science:
- Neurology
- Vascular Neurology
- Cerebrovascular Disease
Background:
- Posterior circulation ischemia represents a significant cause of stroke.
- Understanding the specific patterns and causes of proximal territory ischemia is crucial for targeted treatment.
Purpose of the Study:
- To investigate the distribution, etiological factors, and long-term outcomes of proximal intracranial posterior circulation ischemia.
- To differentiate the causes of lateral medullary infarcts versus posterior inferior cerebellar artery (PICA) territory cerebellar infarcts.
Main Methods:
- Retrospective analysis of 91 patients with proximal intracranial posterior circulation ischemia.
- Inclusion of imaging and comprehensive vascular studies for all participants.
- Follow-up assessment of patient outcomes and mortality.
Main Results:
- 52% of strokes were limited to the proximal territory; 48% involved other posterior circulation areas.
- Posterior inferior cerebellar artery (PICA) territory infarcts (85%) and lateral medullary infarcts (30%) were most common.
- Embolism (intra-arterial or cardiac) was a more frequent cause than intracranial vertebral artery (ICVA) disease for PICA infarcts.
Conclusions:
- Proximal posterior circulation infarcts have distinct etiological profiles for lateral medullary and PICA territory lesions.
- Despite initial mortality, surviving patients with posterior circulation ischemia generally experience favorable long-term outcomes with minimal disability.
Abstract:
We studied 91 patients with proximal intracranial territory posterior circulation ischemia from the New England Medical Center Posterior Circulation Registry to learn their distribution, underlying cardiovascular causes and longterm outcome. All patients had imaging and vascular studies. Six patients had proximal territory TIAs. Among 85 stroke patients, 52% had infarcts limited to the proximal territory, while 48% also had infarcts in other intracranial posterior circulation territories. Eighty-five percent of proximal territory infarcts were posterior inferior cerebellar artery (PICA) territory cerebellar infarcts and 30% were lateral medullary infarcts. One patient had a hemimedullary syndrome. Six patients had PICA territory cerebellar and lateral medullary infarcts. The most common vascular lesion in lateral medullary infarct patients was ipsilateral intracranial vertebral artery (ICVA) disease (38% isolated ICVA disease) and in PICA territory cerebellar infarcts, extracranial vertebral artery (ECVA) disease (29% isolated ECVA disease). Half of all lateral medullary infarcts were due to a hemodynamic mechanism, most often in situ thrombosis of an ICVA occlusive lesion. Half of all PICA territory cerebellar infarcts were due to intra-arterial embolism and one-fifth to cardiac origin embolism. Embolism was a more frequent cause of proximal territory posterior circulation infarcts than intrinsic ICVA disease. The etiological profiles of lateral medullary and PICA cerebellar infarcts were different. Seventeen percent of all patients died during follow-up (41 months) but mortality related to the acute stroke or new strokes was only 6 percent. The outcome was favorable in the surviving patients; 89% had no or only slight disability.