Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

Abstract

Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20-25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of-frequently non-specific-symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.

Keywords: diagnostic error; emergency department; misdiagnosis; posterior circulation; stroke.

Figure 1

Posterior circulation vasculature. The vessels of the posterior circulation can cause multi-level strokes in different anatomical regions of the posterior circulation. The complexity of especially the structures in the brainstem makes localization of clinical signs and the site of infarction more difficult than in the anterior circulation. Angiography of the left vertebral and basilar artery. PCA, posterior cerebral artery; SCA, superior cerebellar artery; BA, basilar artery; AICA, anterior inferior cerebellar artery; PICA, posterior inferior cerebellar artery; VA, vertebral artery; distribution according to the New England Medical Center Posterior Circulation Stroke Registry (3). (Image courtesy of C. Herweh, Frankfurt).

Figure 2

Most common symptoms in posterior circulation stroke as reported in the three large registries. NEMC-PCR, New England Medical Center Posterior Circulation Registry (23); CSR, Chengdu Stroke Registry (24); IPCS-SQR, Ischaemic Posterior Circulation Stroke in the state of Qatar Registry (25).

Figure 3

Pitfalls associated with the diagnosis of PCS in the chain of acute stroke care and suggested approaches to solution. CT, computed tomography; MRI, magnetic resonance imaging; PCS, posterior circulation stroke.