TY - JOUR
T1 - Pearls for the Emergency Clinician
T2 - Posterior Circulation Stroke
AU - Pelletier, Jessica
AU - Koyfman, Alex
AU - Long, Brit
N1 - Publisher Copyright:
© 2023
PY - 2023/11
Y1 - 2023/11
N2 - Background: Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. Objective of the Review: This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. Discussion: PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. Conclusions: An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
AB - Background: Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. Objective of the Review: This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. Discussion: PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. Conclusions: An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
KW - dizziness
KW - neurology
KW - posterior circulation stroke
KW - stroke
KW - vertigo
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U2 - 10.1016/j.jemermed.2023.07.007
DO - 10.1016/j.jemermed.2023.07.007
M3 - Article
C2 - 37806810
AN - SCOPUS:85173280140
SN - 0736-4679
VL - 65
SP - e414-e426
JO - Journal of Emergency Medicine
JF - Journal of Emergency Medicine
IS - 5
ER -