Management of Posterior Circulation Stroke

Clinical Presentation and Diagnosis

The American Heart Association recommends that patients presenting with posterior circulation stroke symptoms, such as ataxia, cranial nerve deficits, visual field loss, dizziness, imbalance, and incoordination, require immediate emergency department evaluation 2, 3, 4
The American Stroke Association suggests that binocular diplopia, dysarthria, dysphagia indicate posterior circulation involvement 5, 6
The American College of Cardiology states that the single most important piece of information is time of symptom onset, defined as when the patient was last known to be at baseline or symptom-free 7
Patients presenting within 48 hours with posterior circulation symptoms are at very high risk for recurrent stroke 5, 6

The American College of Radiology recommends that non-contrast head CT must be performed immediately to exclude intracranial hemorrhage, though it has poor sensitivity (~10%) for detecting posterior fossa ischemic strokes 1, 8
CT should be completed within 25 minutes of arrival, with interpretation within 45 minutes, according to the American College of Emergency Physicians 9
MRI head without contrast is the preferred imaging modality for suspected posterior circulation stroke due to superior sensitivity for posterior fossa lesions, as stated by the American Academy of Neurology 8
CTA or MRA from aortic arch to vertex should be performed urgently within 24 hours to evaluate for large vessel occlusion and determine thrombectomy eligibility, recommends the American Heart Association 8, 5, 6, 9

The American Heart Association strongly recommends intravenous rtPA (0.9 mg/kg; maximum 90 mg) for carefully selected patients who can receive medication within 3 hours of symptom onset 1
The American Stroke Association states that posterior circulation strokes have similar benefits and lower hemorrhage risks compared to anterior circulation when treated with thrombolysis 1
The American College of Cardiology recommends that elevated blood pressure should be lowered cautiously 1
The American Academy of Neurology suggests that temperature should be verified at least four times daily for three days, treating if >37.5°C 9

The American Heart Association recommends that urgent treatment must include measures protecting airway, breathing, and circulation, especially in seriously ill or comatose patients 1
The American College of Chest Physicians states that oxygen saturation should be monitored, with supplemental oxygen only if <94% 9
The American Diabetes Association recommends that blood glucose should be monitored at least four times daily for the first three days 9
The American College of Cardiology suggests that aspirin can be administered within the first 48 hours due to reasonable safety and small benefit 1

The American Heart Association recommends that comprehensive stroke unit care, including rehabilitation, should be provided to a broad spectrum of patients 1
The American Stroke Association states that organized stroke care increases the number of patients who can be treated 1
The American College of Physicians recommends that subsequent hospital treatment should include measures to prevent medical/neurological complications and evaluation to determine stroke etiology for secondary prevention 1