|Year : 2016 | Volume
| Issue : 2 | Page : 65-69
A comparative clinical study of the characteristics of patients with posterior and anterior circulation ischemic strokes
Mohammed El-Sherif1, Ahmed Esmael1, Ayman A Elazzouny2
1 Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Neurology, Misr University for Sciences and Technology, Cairo, Egypt
|Date of Submission||20-Jan-2016|
|Date of Acceptance||27-Mar-2016|
|Date of Web Publication||2-Jun-2016|
MD, Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35516, Dakahlia
Source of Support: None, Conflict of Interest: None
Anterior circulation infarction (ACI) accounts for almost 70% of all strokes, whereas posterior circulation infarction (PCI) accounts for 20% of the strokes, with heterogeneous clinical manifestations.
The aim of the present study was to compare the clinical characteristics of ACI with PCI, and to detect the diagnostic importance of specific symptoms and signs for PCI.
Patients and methods
We prospectively analyzed acute ischemic cerebral stroke (AICS) patients, enrolled in the study from the convalescence and critical cases of Mansoura University Hospitals (CCCB-MUH) during a 1-year period. Patients were analyzed for ischemic stroke subtypes (ACI and PCI), demographic data, risk factors, and clinical characteristics. All patients underwent an assessment by using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale at the onset of AICS.
The study included 234 patients with AICS (174 belonging to the ACI subtype; 60 to the PCI subtype). PCI patients were often men, had a higher presence of cervical spondylosis, lower mean National Institutes of Health Stroke Scale, and a lower mean Glasgow Coma Scale. PCI patients had a greater frequency of diabetes and smoking. Among the PCI patients, ataxia, vertigo, unsteadiness, nystagmus, crossed motor, and sensory deficits were statistically significant compared with the ACI patients. As regards speech disturbances, aphasia occurred in a low percentage of the PCI patients, and no statistically significant difference regarding dysarthria was found in the two groups. The neurological deficits favoring the diagnosis of PCI were nystagmus, crossed motor and sensory deficits, ataxia, vertigo, unsteadiness, diplopia, Horner's syndrome, and oculomotor nerve palsy.
There is an apparent difference in the frequency of the most common manifestations between PCI and ACI patients. Some neurological deficits were highly specific for diagnosing PCI.
Keywords: Ischemic cerebrovascular disease, risk factors, stroke scales
|How to cite this article:|
El-Sherif M, Esmael A, Elazzouny AA. A comparative clinical study of the characteristics of patients with posterior and anterior circulation ischemic strokes. Egypt J Neurol Psychiatry Neurosurg 2016;53:65-9
|How to cite this URL:|
El-Sherif M, Esmael A, Elazzouny AA. A comparative clinical study of the characteristics of patients with posterior and anterior circulation ischemic strokes. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2017 Jun 26];53:65-9. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/2/65/183404
| Introduction|| |
The similarities in their neurological manifestations make the differentiation between ischemic cerebrovascular disease subtypes challenging. As major decisions, like revascularization, sometimes rely on the conjunction between certain patient symptoms and occlusion in a specific cerebral blood vessel branch, the certainty of localization is very important for the clinician .
Anterior circulation infarction (ACI) accounts for almost 70% of all strokes, whereas posterior circulation infarction (PCI) is responsible for about 20%, with heterogeneous clinical manifestations ,.
The posterior circulation intracranial part is more vulnerable to atherosclerosis when compared with the cerebral anterior circulation. While in ACI, the proximal 2cm of the origin of the internal carotid artery is the most frequent location of occlusion and intracranially it is the carotid siphon. The internal carotid artery occlusion is often quiet because of the presence of collateral circulation, which can open again if the occlusion happens steadily over a period of time ,,.
The occurrence of long-established brainstem and cerebellar manifestations was used to describe PCI. A significant numbers of PCIs patients may lack the classic clinical manifestations. The fault diagnosis consistently arises in the early stage of patient assessment, which may cause inaccurate clinical decision-making.
MRI-based researches stated that unilateral limb weakness or numbness, nausea/vomiting, and headache are the importance clinical manifestations in PCI rather than crossed paralysis, crossed sensory deficits, visual field disturbance, isolated vertigo, and dysphagia ,,,.
| Aim of the work|| |
In the present study, we tried to differentiate between the clinical manifestations of ACI and PCI and to detect the diagnostic value of specific symptoms and signs for PCI.
| Patients and methods|| |
The present prospective study included patients with ischemic stroke who were admitted to the convalescence and critical cases in Mansoura University Hospitals. We excluded patients who were admitted to our hospital more than 2 weeks after the onset; patients with numerous infarcts influencing both posterior and anterior circulation; and patients with premorbid conditions, such as previous stroke, uremia, cancer, and degenerative diseases, which may confound the neurological examination. All patients were subjected to clinical evaluation, which included careful history taking and complete clinical examination using the Mansoura Neurology Department data sheet.
The National Institutes of Health Stroke Scale score is used as a measurable scale for assessing cerebral stroke . The Glasgow Coma Scale is a clinical scale that gives a dependable, objective method of estimating the consciousness level of a patient for primary and follow-up assessment . Regarding the radiological evaluation, the brain imaging was performed using a 1.5-T MRI machine (Symphony; Siemens AG Medical Systems, Forchheim, Germany). Diffusion-weighted imaging had the following variables: b-values of 0, 500, and 1000mm 2 /s, whereas TR/TE of 1000/108ms, band width of 125kHz, and slice thickness of 4mm.
The vascular cerebral branches were classified first into the posterior circulation, which consists of the posterior cerebral artery, cerebellar arteries, the circumferential branches of the basilar artery (superior, anterior inferior, and posterior inferior), and cerebellar watershed; and, second, into the anterior circulation, which consists of the anterior cerebral artery, the middle cerebral artery (lenticulostriate, inferior division, and superior division), a single penetrating artery in the deep structure (white matter), watershed, and the anterior choroidal artery. We relied on Damasio's template mapping , which charts the major divisions of anterior infarction, and on Bogousslavsky's standards  to help in the classification of PCI and ACI.
Patients were classified into two groups according to infarctions involving either the posterior circulation or the anterior circulation . Cervical spondylosis was investigated as reported by the patient's cervical plain film or by using MRI data. Laboratory investigations included complete blood picture, lipogram, random blood sugar, liver and kidney function tests to search for stroke risk factors such as diabetes mellitus, hypertension, heart disease (which included valvular heart disease, arrhythmia, coronary heart disease, or heart failure), and dyslipidemia (described as taking statins, or low-density lipoprotein >130mg/dl, or an overnight fasting cholesterol >200mg/dl).
Differences in demographics, risk factors, and the frequency of categorical variables between the PCI and ACI were evaluated by using Fisher's exact test and the χ2 -test. To assess the diagnostic value of symptoms/signs, the odds ratio with 95% confidence interval was calculated. Statistical analyses were carried out by using the SPSS package (version 16.0 for Windows; SPSS Inc., Chicago, Illinois, USA).
| Results|| |
The study comprised 234 patients with ischemic stroke [174 belonging to the ACI subtype (74.4%); 60 to the PCI subtype (25.6%)]. There were 141 men and 93 women, with a male to female ratio of 1.5:1 and with a mean age of 60.65 ± 14.3 years (range = 46-75 years). Patients' demographic data, risk factors, and clinical scales showed that on comparing PCI with ACI, patients with PCI were more often men, had a higher presence of cervical spondylosis, lower mean National Institutes of Health Stroke Scale, and a lower mean Glasgow Coma Scale. PCI patients had a greater frequency of diabetes and smoking, but a lower frequency of atrial fibrillation [Table 1].
|Table 1: Demographic data, risk factors, and clinical scales of the studied patients|
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The comparison between PCI and ACI regarding neurological manifestations showed that among the PCI patients, ataxia, vertigo, unsteadiness, nystagmus, crossed motor and sensory deficits, diplopia and nausea and vomiting were statistically significant compared with the ACI patients [Table 2].
|Table 2: Neurological manifestations for the diagnosis of percutaneous coronary intervention|
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The neurological deficits with the highest predictive value, favoring the diagnosis of PCI were nystagmus, followed by crossed motor and sensory deficits, ataxia, vertigo, unsteadiness, diplopia, Horner's syndrome, oculomotor nerve palsy, nausea/vomiting, and visual field defect [Table 3].
|Table 3: Neurological deficits predictors for diagnosing patients with percutaneous coronary intervention|
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| Discussion|| |
MENA (Middle East and North Africa) countries are inhabited by dissimilar people with identical lifestyle, food habits, and cerebral stroke risk factors, which may impact stroke risk, types, prevalence, and disease cost. The most populous nation in the Middle East (85.5 million people) is Egypt, with a cerebral stroke prevalence rate of 963/100 000 citizens .
The current study was designed as a selective study to examine Egyptian patients with ischemic cerebral stroke either ACI or PCI who were admitted at CCCB-MUH. The study included 234 patients; the inclusion of such a number of patients throughout the study duration (1 year) sheds light on the increased incidence of ischemic stroke in the Egyptian population.
The current study noted that among the neurological features, homolateral paralysis had the highest incidence, followed by central facial/lingual palsy and hemisensory deficits in PCI; besides, these were the three most common features in ACI. Earlier studies compared the frequencies of the neurological manifestations in PCI cases, but these studies did not compare PCI patients with ACI patients ,. The clinical features showed the heterogeneous presentations in these earlier studies, which was in agreement with the present study. Nonetheless, homolateral paralysis and facial palsy were also found to be the most prevent manifestations in PCI cases.
Savitz and Caplan  stated that unilateral limb weakness was the most frequent sign in the PCI patients. Hemiparesis and tetraparesis were the most common signs for patients with midbrain infarction ,. Moreover, pure motor hemiparesis or hemiplegia was detected in a large percentage of cases . These findings are in agreement with those in our study that PCI cases with homolateral paralysis are frequent in the neurology clinical practice.
We have to consider symptoms/signs that act as pathognomonic findings in the diagnosis of PCI, such as crossed motor/sensory deficits, oculomotor nerve palsy, visual field deficits, and Horner's syndrome. This is in agreement with one earlier study that concluded that roughly 10-20% of cases with a diagnosis of supposed ACI indeed have a PCI .
As reported before, crossed signs are pathognomonic features that point to brainstem implication . In recent studies, crossed motor and sensory manifestations appeared occasionally [in five patients (2.1%) with PCI and in no patient with ACI].
Kim  stated that the rate of crossed deficits was high, and the correlations between infarct topography and the crossed motor/sensory signs in PCI patients were not well observed. The findings of the present study were in contrast to the traditionally held belief that disturbed consciousness is highly specific for PCI. Many studies showed patients with specific vertebrobasilar lesions, particularly the midbrain, cerebellum, and basilar artery occlusive disease individually; the degree of disturbed consciousness was high, mostly 20% ,.
Sato and colleagues reported a much lower degree of disturbed consciousness in cases with PCI than in cases with ACI. This was not in agreement with our study in which disturbed consciousness appeared to be higher in patients with PCI than in those with ACI (12/60 cases, 20% vs. 27/174 cases, 15.5%) . These dissimilarities in different studies can be attributed to a diverse dissemination of stroke subtypes or different age groups included.
In the current study, nausea/vomiting, vertigo, and headaches were established to be the manifestations that occur more regularly in patients with PCI. As the circulation to the inner ear arises from the vertebrobasilar system, the vertebral artery disease can cause vertigo, which is usually accompanied by other brainstem or cerebellar symptoms ,. Savitz and Caplan  stated that isolated vertigo has been rarely determinable to PCI; this was not in agreement with our observations, as 12 patients with PCI had vertigo.
| Conclusion|| |
There is an apparent difference in the frequency of the most common symptoms/signs between PCI and ACI. Some neurological deficits were highly specific for diagnosing PCI and were of good predictive value.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tao WD, Liu M, Fisher M, Wang DR, Li J, Furie KL, et al.
Posterior versus anterior circulation infarction: how different are the neurological deficits? Stroke 2012; 43(8): 2060-2065.
Roivainen R, Haapaniemi E, Putaala J, Kaste M, Tatlisumak T. Young adult ischaemic stroke related acute symptomatic and late seizures: risk factors. Eur J Neurol 2013; 20(9): 1247-1255.
Arboix A, Arbe G, García-Eroles L, Oliveres M, Parra O, Massons J. Infarctions in the vascular territory of the posterior cerebral artery: clinical features in 232 patients. BMC Res Notes2011;; 4:329.
Glass TA, Hennessey PM, Pazdera L, Chang HM, Wityk RJ, Dewitt L, et al.
Outcome at 30 days in the New England Medical Center Posterior Circulation Registry. Arch Neurol 2002; 59:359-376.
Caplan LR, editor. Vertebrobasilar territory ischemia: an overview. In: Posterior circulation disease: clinical findings, diagnosis, and management. Cambridge, England: Blackwell Science Ltd; 1996. 179-197.
Nighoghossian N, Ryvlin P, Trouillas P, Laharotte JC, Froment JC. Pontine versus capsular pure motor hemiparesis. Neurology 1993; 43(11): 2197-2201.
Chambers BR, Brooder RJ, Donnan GA. Proximal posterior cerebral artery occlusion simulating middle cerebral artery occlusion. Neurology 1991; 41(3): 385-390.
Montavont A, Nighoghossian N, Hermier M, Derex L, Berthezène Y, Philippeau E, et al.
Hemiplegia in posterior cerebral artery occlusion: acute MRI assessment. Cerebrovasc Dis 2003; 16:452-453.
Kumral E, Bayulkem G, Akyol A, Yunten N, Sirin H, Sagduyu A. Mesencephalic and associated posterior circulation infarcts. Stroke 2002; 33:2224-2231.
Lyden P, Raman R, Liu L, Grotta J, Broderick J, Olson S, et al.
NIHSS training and certification using a new digital video disk is reliable. Stroke 2005; 36:2446-2449.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2(7872): 81-84.
Damasio H. A computed tomographic guide to the identification of cerebral vascular territories. Arch Neurol 1983; 40(3): 138-142.
Tatu L, Moulin T, Bogousslavsky J, Duvernoy H. Arterial territories of the human brain: cerebral hemispheres. Neurology 1998; 50:1699-1708.
Tao WD, Kong FY, Hao ZL, Lin S, Wang DR, Wu B, et al.
One-year case fatality and disability after posterior circulation infarction in a Chinese hospital-based stroke study. Cerebrovasc Dis 2010; 29:376-381.
Abd-Allah F, Moustafa RR. Burden of stroke in Egypt: current status and opportunities. Int J Stroke 2014; 9:1105-1108.
Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol 2012; 69(3): 346 -351.
Akhtar N, Kamran SI, Deleu D, D′Souza A, Miyares F, Elsotouhy A, et al.
Ischaemic posterior circulation stroke in State of Qatar. Eur J Neurol 2009; 16(9): 1004 -1009.
Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005; 352(25): 2618-2626.
Voetsch B, DeWitt LD, Pessin MS, Caplan LR. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol 2004; 61(4): 496 -504.
Ling L, Zhu L, Zeng J, Liao S, Zhang S, Yu J, Yang Z. Pontine infarction with pure motor hemiparesis or hemiplegia: a prospective study. BMC Neurol. 2009; 9:25.
Argentino C, De Michele M, Fiorelli M, Toni D, Sacchetti ML, Cavalletti C, et al.
Posterior circulation infarcts simulating anterior circulation stroke. Perspective of the acute phase. Stroke 1996; 27(8): 1306 -1309.
KK Sinha. Brain stem infarction: clinical clues to localise them. Indian Acad Clin Med 2000; 1:213-221.
Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain 2003; 126(Pt 8): 1864 -1872.
Sato S, Toyoda K, Uehara T, Toratani N, Yokota C, Moriwaki H, et al.
Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes. Neurology 2008; 70(Pt 2): 2371-2377.
Lee CC, Su YC, Ho HC, Hung SK, Lee MS, Chou P, Huang YS Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study. Stroke 2011; 42(1): 48 -52.
Smith WS, Johnston SC, Hemphill JC. Cerebrovascular disease. In: Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J, editors Harrison′s principle of internal medicine
. New York, NY: McGraw Hill; 2015. 2559-2586.
[Table 1], [Table 2], [Table 3]