Posterior circulation stroke, its pitfalls in diagnosis and best management strategy
Presentations of case resolutions in the form of a “serious game”. Severe stroke of posterior circulation clinically mimicking anterior circulation occlusion in a patient with a very short time to onset of symptoms. Interesting discussion on:
- straight to angio vs. conventional imaging strategy
- aspiration vs. stent-retriever thrombectomy in posterior circulation
- radial vs. femoral approach.
Posterior circulation stroke can mimic anterior circulation stroke, CTP may be advantageous to point out the lesion and increase sensitivity of clot detection when CTA does not give straightforward diagnosis.
Straight to angio management:
- advantages: time saving, especially when drip and ship
- disadvantages: time wasting when difficult anatomy and no prior imaging (tortuous cervical vessels, variants of the aortic arch).
Distal injection from microcatheter:
- advantages: may help to confirm the proper position of microcatheter and vessel diameter
- disadvantages: risk of clot fragmentation
Aspiration vs stent-retirever strategy:
In posterior circulation SLICE Academy prefer aspiration over the stent-retriever:
- good aspiration force in straight segment of vessel like BA compare to some tortous MCA
- clot is not compacted into the top-BA because of the retrograde flow from PCA and may be easy to retrieve
- less chance to occlude perforators while retrieving the clot compare to MT with stent-retriever
Based on publication (retrospective study):
- no difference in clinical outcome in aspiration vs. stent-retriever in posterior stroke
- trend toward a higher successful reperfusion rate and significantly higher rate of complete reperfusion in aspiration but longer procedure time compare to stent-retirevers
- removal of the microcatheter strategy (advantages: higher aspiration force)
- keeping the microcatheter in place strategy (advantages: reducing the length of stent-retriever to reduce the friction force, protection of aspiration catheter from damage)
- when VA arising from posterior side of the artery it is usually more difficult to catheterize it, the use of cobra shape sheath may be beneficial in some cases
Pitfalls in secondary prevention of stroke:
Patient having LVO being already on aspirin - should we introduce or switch to another antiplatelet/ anticoagulant medication?
It might be considered in LVO and large burden clot to give those patients anticoagulation despite the fact that you haven’t found the source of thrombus yet - bridging therapy until the cause of stroke found.