New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes

Lr Caplan, C-S Chung, Rj Wityk, Ta Glass, J Tapia, L Pazdera, H-M Chang, Jf Dashe, Cj Chaves, K Vemmos, M Leary, Ld Dewitt, Ms Pessin, Lr Caplan, C-S Chung, Rj Wityk, Ta Glass, J Tapia, L Pazdera, H-M Chang, Jf Dashe, Cj Chaves, K Vemmos, M Leary, Ld Dewitt, Ms Pessin

Abstract

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs before strokes, and 16% had only posterior circulation TIAs. Embolism was the commonest stroke mechanism accounting for 40% of cases (24% cardiac origin, 14% arterial origin, 2% had potential cardiac and arterial sources). In 32%, large artery occlusive lesions caused hemodynamic brain infarction. Stroke mechanisms in the posterior and anterior circulation are very similar. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes), while the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Infarcts that included the distal territory were twice as common as those that included the proximal or middle territories. Most distal territory infarcts were attributable to embolism. Thirty day mortality was low (3.6%). Embolic stroke mechanism, distal territory location, and basilar artery occlusive disease conveyed the worst prognosis.

Keywords: Basilar artery; Brain embolism; Brain ischemia; Posterior circulation; Vertebral arteries.

Figures

Figure 1
Figure 1
Sketch of the base of the brain showing the intracranial vertebral and basilar arteries and their branches. The brain is divided into proximal, middle, and distal intracranial territories. ASA; anterior spinal artery, PICA; posteroinferior cerebellar artery, AICA; anteroinferior cerebellar artery, SCA; superior cerebellar artery, PCA; posterior cerebral artery. Redrawn by Laurel Cook-Lowe with permission from Duvernoy HM. Human Brainstem Vessels. Berlin: Springer-Verlag, 1978.
Figure 2
Figure 2
Age ranges of patients in the NEMC-PCR.
Figure 3
Figure 3
(A) Brain territory locations in the NEMC-PCR. (B) Pie chart showing distribution of brain locations. P; proximal, M; middle, d; distal posterior circulation territories
Figure 4
Figure 4
Locations of infarcts within the proximal intracranial posterior circulation territory. PICA; Posterior inferior cerebellar artery territory
Figure 5
Figure 5
Locations of infarcts within the middle intracranial posterior circulation territory. AICA; Anterior Inferior cerebellar artery territory
Figure 6
Figure 6
Locations of infarcts within the distal intracranial posterior circulation territory. SCA; superior cerebellar artery (SCA) territory of the cerebellum, PCA; occipital and temporal lobe territories of the posterior cerebral arteries (PCAs), Rostral stem; midbrain and thalamus
Figure 7
Figure 7
Brain locations within the posterior circulation in patients with various stroke mechanisms. IA; Intraarterial

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