Treatment of posterior circulation stroke: Acute management and secondary prevention

 If we had a decent database of all stroke research that was updated every time there was new research we wouldn't have to waste time on these systematic reviews. Then we could have researchers doing the important work of solving for 100% recovery protocols. But alas, we have NO STROKE LEADERSHIP directing anything.

Treatment of posterior circulation stroke: Acute management and secondary prevention

Hugh S Markus, Patrik Michel

First Published June 28, 2022 Review Article Find in PubMed 

https://doi.org/10.1177/17474930221107500

Article information

Abstract

One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulation stroke differs from that of stroke in general and highlight recent advances.

Effectiveness of acute revascularization of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower hemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy.

Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions and short-term dual anti-platelet therapy. Randomized controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

Keywords

Vertebral, basilar, posterior circulation, vertebrobasilar, stenting, acute stroke therapy, treatment, prevention

Introduction

Stroke is globally the second leading cause of death and the third cause of death and disability.¹ One-fifth of strokes occur in the vertebrobasilar territory (also known as posterior) circulation.² Diagnosis of posterior circulation stroke and transient ischemic attack (TIA) can be more challenging than anterior circulation syndromes, and widely used screening protocols such as the face-arm-speech test (FAST) are less sensitive.³ Optimal management of posterior circulation stroke, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation.³ However, recent research and ongoing studies are improving our understanding. In this review, we cover the treatment of posterior circulation stroke, covering both interventions in the acute setting and secondary prevention. We focus on areas in which management of posterior circulation stroke differs from that of stroke in general and highlight recent advances.