Posterior circulation ischaemic stroke diagnosis and management

Abstract

This narrative review provides an overview of the posterior circulation and the clinical features of common posterior circulation stroke (PCS) syndromes in the posterior arterial territories and how to distinguish them from mimics. We outline the hyperacute management of patients with suspected PCS with emphasis on how to identify those who are likely to benefit from intervention based on imaging findings. Finally, we review advances in treatment options, including developments in endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), and the principles of medical management and indications for neurosurgery. Observational and randomised clinical trial data have been equivocal regarding EVT in PCS, but more recent studies strongly support its efficacy. There have been concomitant advances in imaging of posterior stroke to guide optimal patient selection for thrombectomy. Recent evidence suggests that clinicians should have a heightened suspicion of posterior circulation events with the resultant implementation of timely, evidence-based management.

Keywords: basilar artery occlusion; endovascular thrombectomy; posterior circulation; posterior stroke; stroke; thrombolysis.

Fig 1

Anatomy of the posterior circulation. Created with BioRender (BioRender.com).

Fig 2

Example infarcts in the posterior circulation (asterisks). (a) Axial non-contrast CT image of a left posterior cerebellar artery infarct with mass effect. (b) Axial MRI DWI image of a large acute left-sided pontine infarct. (c) Axial MRI ADC image of a large acute left-sided pontine infarct. (d) Coronal MRI T1 image of an acute left-sided pontine infarct. (e) Axial non-contrast CT image showing an infarct on the medial aspect of the left cerebellum representing a superior cerebellar artery infarct. (f) Axial T2 MRI image of a bilateral caudal midbrain infarct. (g) Sagittal MRI T2 image with medullary infarct. (h) Sagittal MRI DWI image with restricted diffusion in medullary infarct. (i) Axial CT perfusion image showing time to maximum (Tmax, false colour scale in seconds), with bilateral cerebellar hypoperfusion in basilar artery occlusion. ADC = apparent diffusion coefficient; CT = computed tomography; DWI = diffusion-weighted image; MRI = magnetic resonance imaging.