Basilar artery stroke

Sean Ruland DO (Dr. Ruland of the Stritch School of Medicine at Loyola University Chicago has no relevant financial relationships to disclose.)
Sarkis Morales-Vidal MD (Dr. Morales-Vidal of the Stritch School of Medicine at Loyola University of Chicago has no relevant financial relationships to disclose.)
Murray Flaster MD PhD (Dr. Flaster of the Stritch School of Medicine at Loyola University of Chicago has no relevant financial relationships to disclose.)
Jose Biller MD (Dr. Biller of the Stritch School of Medicine at Loyola University of Chicago has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released October 28, 1997; last updated April 30, 2017; expires April 30, 2020

This article includes discussion of basilar artery stroke, basilar insufficiency, vertebrobasilar insufficiency, VBI, basilar branch artery stroke, and dolichoectasia of the basilar artery. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Infarcts in the distribution of the basilar artery are perhaps the most feared and devastating of all ischemic strokes. However, an important minority of patients can have good outcomes, especially with time-sensitive treatment approaches. This article reviews 4 distinct syndromes of basilar artery stroke, including proximal and middle basilar artery occlusions, top of the basilar syndrome, basilar artery branch occlusions, and dolichoectasia of the basilar artery. Pertinent vertebral and basilar artery anatomy is discussed. Emerging assessment and treatment strategies for acute basilar artery occlusion and the merits of antiplatelet versus anticoagulant therapy for prevention of recurrent basilar artery stroke are reviewed. Potential causes of posterior circulation stroke are highlighted. Finally, pediatric stroke in the posterior circulation and intravenous lytic use in children and during pregnancy are also discussed.

Historical note and terminology

The first clinic-pathologic report of basilar artery occlusion appeared in 1868 by Hayem (Hayem 1868). In 1882, Leyden reviewed prior cases of basilar artery occlusion, reported 2 additional clinic-pathologic cases of his own, described aneurysmal dilation of the basilar artery, and discussed the differential diagnosis between atherosclerotic basilar artery disease and superimposed thrombosis, embolism to the basilar artery, and syphilitic basilar artery endarteritis with thrombosis (Leyden 1882). His discussion of 3 patients who presented with sudden (but nonfatal) bulbar signs, presumed to have basilar artery thrombosis, probably represents the first recorded instance of basilar artery stroke. Charles Dana, a leading American neurologist, wrote an extensive review of infarctions and hemorrhages of the pons and medulla (Dana 1903). He surveyed 39 autopsied cases of lower brainstem infarction and noted that many patients had prodromal transient attacks of hemiparesis, vertigo, dysarthria, and double vision during the months or years preceding their major strokes. He divided the clinical presentation into 2 major categories: (1) long tract motor and sensory dysfunction and (2) bulbar symptoms and signs. Foix and Hillemand published a detailed review of pontine infarcts and the anatomy of the basilar artery and its branches (Foix and Hillemand 1926).

Kubik and Adams' classic report on basilar artery occlusion in 1946 shaped modern conceptions of pathology and pathogenesis of basilar artery steno-occlusive disease (Kubik and Adams 1946). They analyzed 18 necropsy cases, concluding that basilar artery occlusions are characterized by frequent early loss of consciousness, common bilateral involvement, and combinations of pupillary disturbance, ocular and other cranial nerve palsies, dysarthria, Babinski signs, hemiplegia or quadriplegia, and often a marked remission of symptoms. Biemond emphasized amnesia, hemianopsia, and other posterior cerebral artery manifestations of basilar artery distribution ischemia (Biemond 1951). Millikan and Siekert detailed vertebrobasilar transient ischemic attacks ("vertebrobasilar insufficiency") and advocated anticoagulants as therapy. Kemper and Romanul described a patient with the loss of the ability to communicate due to limb and bulbar paralysis, a condition later coined "locked-in syndrome." A public light was shed on this rare and devastating disorder with the 1997 publication and film of the same name in 2007, Le Scaphandre et le Papillon (The Diving Bell and The Butterfly) a moving, first-person account by Jean-Dominique Bauby, former Editor-in-Chief of the French magazine Elle and a victim of a basilar artery stroke. The locked-in syndrome had already been depicted in Alexandre Dumas's novel The Count of Monte Cristo, when he created Monsieur Noirtier de Villefort. Dumas described his character as a “corpse with living eyes” (Williams 2003). Caplan described the "top of the basilar syndrome” and attributed it to embolic occlusion of the distal basilar artery producing ischemia of the rostral brainstem and the posterior cerebral artery territories (Caplan 1980).

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