brain infarction - posterior circulation

INTRODUCTION: Acute large vessel occlusive, ischaemic strokes may benefit from endovascular recanalisation strategies. A delayed diagnosis of an acute large vessel occlusion could be avoided if it was possible to identify clinical and radiological data predictive of large vessel occlusions and the affected vascular circulation (anterior vs. posterior circulation). METHODS: All consecutive patients (2003–2011) in ASTRAL, a prospective single-centre registry of acute ischaemic strokes, were selected if a symptomatic, large vessel occlusion was found on CTA performed <12 h after stroke onset. Stroke was localised to anterior and posterior circulation using acute and follow-up radiological information. RESULTS: In 757 of 1523 patients with a large vessel occlusion (56 % anterior and 33 % posterior circulation strokes), multiple logistic regression analysis showed an association of anterior circulation occlusion with aphasia (OR 53.1, 95 %CI 16.1-175.9), hemineglect (32.2, 10.4-99.8), hemiparesis (4.8, 1.3-17.4) and hemisensory deficits (6.3, 2.6-15.3); and of posterior circulation occlusion with cerebellar (0.1, 0.0-0.1), visual field (0.1,0.0-0.2) and posterior-fossa-type oculomotor deficits (perfect prediction). Anterior circulation strokes had shorter onset-to-door interval (0.9, 0.9-1.0), higher admission diastolic blood pressure (1.1, 1.0-1.1) and more often early ischaemic signs on non-contrast CT (0.7, 0.5-0.9). ROC analysis showed an area under the ROC curve of 0.98. CONCLUSIONS: In acute large vessel occlusive strokes, posterior circulation localisation can be inferred by later presentation to the hospital, fewer cognitive, fewer sensory-motor and more cerebellar deficits, lower blood pressure and normal non-contrast CT. Clinical implementation may help to guide future recanalisation strategies.