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vertebrobasilar stroke

Etiology: 1) embolism, embolic stroke (largely from heart) 40% 2) large artery disease 32%, arteritis, giant cell arteritis [4] 3) penetrating artery disease 14% Pathology: - vascular occlusive lesions a) extracranial vertebral artery 32% b) intracranial vertebral artery 22% c) basilar artery 30% - symptoms attributable to ischemia of: - medulla, pons, midbrain, cerebellum, thalamus, occipital cortex [3] - supplied by: - posterior inferior cerebellar artery - anterior inferior cerebellar artery - superior cerebellar artery - posterior cerebral artery [3] Clinical manifestations: 1) dysarthria 2) vertigo - 20% of patients present with isolated vertigo [5] 3) ataxia 4) diplopia [3] 5) visual field loss [3] 6) perioral paresthesias 7) acute confusional state 8) profound general weakness 9) focal neurologic signs [3] 10) hypertensive urgency -> hypertensive crisis [3] 11) gaze-evoked nystagmus 12) head-thrust test negative Complications: - brainstem herniation [6] Management: - see ischemic stroke - lower blood pressure with labetalol [3] Prognosis: 1) 30 day morbidity & mortality a) 4% mortality b) 18% major disability c) 51% minor disability d) 28% without disability 2) poor outcomes associated with embolism a) 29% of embolic strokes b) 14% of large artery strokes c) 13% of penetrating artery strokes 3) poor outcomes associated with basilar artery lesions

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vertebrobasilar disease vertebrobasilar system

General

ischemic stroke

References

  1. Journal Watch 22(8):62, 2002 Gass TA et al, Arch Neurol 59:369, 2002 Barnett HJM, Arch Neurol 59:359, 2002
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1021-22
  3. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  4. NEJM Knowledge+ Question of the Week. July 19, 2016 http://knowledgeplus.nejm.org/question-of-week/730/
  5. Medical Knowledge Self Assessment Program (MKSAP) 19. American College of Physicians, Philadelphia 2021
  6. NEJM Knowledge+