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  • Updated 03.31.2022
  • Released 10.28.1997
  • Expires For CME 03.31.2025

Basilar artery stroke



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

Key points

• Basilar artery stroke can be a grave condition.

• Basilar artery stroke is most commonly caused by atherothrombosis and cardioembolism.

• Patients with acute ischemic stroke in the basilar artery territory should receive intravenous alteplase, also referred to as tPA, if they qualify according to accepted criteria.

• Patients with large vessel occlusion of the basilar artery should be considered for endovascular thrombectomy, although definitive evidence is lacking from randomized controlled trial data.

• Optimal treatment for patients with dolichoectasia of the basilar artery is uncertain.

Historical note and terminology

The first clinico-pathologic report of basilar artery occlusion appeared in 1868 by Hayem (65). In 1882, Leyden reviewed prior cases of basilar artery occlusion, reported 2 additional clinico-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 (86). 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, in an extensive review of infarctions and hemorrhages of the pons and medulla 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 (36). 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 (53).

Kubik and Adams' classic report on basilar artery occlusion in 1946 shaped modern conceptions of pathology and pathogenesis of basilar artery steno-occlusive disease (76). 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 (20). 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’ novel The Count of Monte Cristo, when he created Monsieur Noirtier de Villefort. Dumas described his character as a “corpse with living eyes” (151). 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 (30).

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