Clinical Profile Of Posterior Circulation Stroke In A Tertiary Care Centre In Southern India Key WordsCorrespondence Address :
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The present study has been undertaken in a tertiary care centre in southern India to known the clinical profile of posterior circulation stroke as there are few studies for the same in that mainly the New England Medical Center – Posterior Circulation Stroke Registry. To the best of our knowledge there are no studies available in literature regarding posterior circulation hemorrhagic strokes in India. A total number of 25 cases were studied during the period from Jan 2010 to Dec 2010 who were admitted to department of Medicine and Neurology in S.Nijalingappa Medical College and HSK Hospital & Research Center. Detailed clinical history was taken in all patients with general physical examination. CBC, urine analysis, random blood sugar, blood urea, serum electrolytes, lipid profile, ECG, CXR, and CT scan were done. In some selected cases CSF analysis, EEG and ECHO were done. Incidence of posterior circulation strokes was 12.31 % and male to female ratio was 3.1:1. Amongst posterior circulation strokes, ischaemic were far commoner than haemorrhagic (76% vs. 24%). The common manifestations were motor disturbances, altered sensorium, headache, speech and visual disturbances in ischaemic strokes. Altered sensorium was present in all cases of haemorrhagic strokes. The commonest predisposing factors were tobacco abuse and hypertension. The commonest neurological findings were altered sensorium, motor disturbances, cranial nerve involvement and cerebellar signs. Infratentorial infarcts were seen more frequently than supratentorial infarcts, in this study. Incidence of mortality was higher in haemorrhagic strokes than ischaemic strokes (50% vs. 26.3%)
Posterior circulation strokes, haemorrhagic strokes, ischaemic strokes
KORA.S.A, DODDAMANI.G.B, PRAMILA DEVI, GOORANNAVAR S.M, BIRADAR SATISH. CLINICAL PROFILE OF POSTERIOR CIRCULATION
STROKE IN A TERTIARY CARE CENTRE IN
KEY WORDS. Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2019 Feb 16 ]; 5:217-221. Available from
Cerebrovascular accidents have been known since ancient times because of the characteristic clinical picture they produce. Hippocrates (470 – 370 B.C.) described stroke as ‘APOPLEXY’, which means astonishment. Leoniceno described syphilitic hemiplegia in 1497. (1) In 1911 Margurg first reviewed the topic of brain stem infarction & described clinical examples of basilar territory syndromes. In 1932 Pines & Gilinsky published detailed report that included serial section of brain stem in a patient with thrombosis of basilar artery. (2) The World Health Organization (WHO) defines stroke as ‘rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than vascular origin”. (3) The National Institute of Neurological Disorders and Stroke (NINDS) apply the term stroke to “any one or all of a group of disorders including cerebral infraction, intracerebral haemorrhage or subarachnoid haemorrhage”. (4)Posterior circulation strokes account for 10 to 15% (5) of all strokes. The area includes brainstem, cerebellum, occipital lobes and thalamus and is supplied by 2 vertebral arteries, 1 basilar artery and 2 posterior cerebral arteries (6). Posterior circulation ischaemia ranges from fluctuating brainstem symptom caused by intermittent insufficiency to many syndromes like lateral medullary, medial medullary, locked in to top of basilar syndrome (7). There are no data available to reflect the true incidence of cerebrovascular disease in Indian population. There are no hospital statistics available for posterior circulation strokes in India, because there is no study conducted in India about the epidemiological incidence. Hence we have decided to study the clinical profile of posterior circulation stroke, as there are very few studies available in literature.
This study was conducted during the period from Jan 2010 to Dec 2010. During this period all posterior circulation strokes admitted to Neurology and Medicine departments of S.Nijalingappa Medical College and HSK Hospital & Research Centre were studied. This study consisted of total 25 posterior circulation strokes.
All posterior circulation strokes were included during the study period. The diagnosis of posterior circulation was made when the patient had a clinical stroke syndrome compatible with involvement of posterior circulation territory with the help of clinical signs and symptoms and by means of classical syndromes like Claude’s, Weber’s, Balint’s, Lateral medullary, Medial medullary, Locked in & top of basilar syndromes.
(7) EXCLUSION CRITERIA:-
If CT scan showed recent infarction, haemorrhage in the anterior circulation and other non-vascular lesions, and then they were excluded from the study sample.
A detailed history was obtained from the patient or a close relative regarding the onset of stroke, risk factors and family history. A detailed physical examination was done according to the proforma including vital signs & detailed examination of other systems. Optic fundus was examined in all the cases.
All the patients were investigated for CBC, ESR, urine analysis, random blood sugar, blood urea, serum electrolytes, lipid profile, RA factor, VDRL, ECG & chest radiography. CT scan was done, in all patients in the study whenever needed CSF, EEG & ECHO was done.
During the study period the total number of strokes were 203 and percentage of posterior circulation stroke was 12.31% of all strokes. Stroke was more common in the middle aged and elderly. Ischaemic stroke was more common in age group 41 to 50 and haemorrhagic stroke in age group 71 to 80.The male to female ratio of stroke was 3.1:1 and both ischaemic and haemorrhagic strokes were more common in males. 76% of the patients had ischaemic strokes and 24% had haemorrhagic strokes. Infratentorial stroke was common in both ischaemic and haemorrhagic stroke. The entire haemorrhagic stroke presented with acute completed stroke and where as only 52.63% of ischaemic stroke patients had acute completed stroke and 47.36% had stepwise progression.Table 2 shows frequency of clinical manifestations at the time of admission to hospital. The most frequent manifestation was motor dysfunction in 63% of ischaemic strokes and history of altered sensorium was 100% in haemorrhagic strokes.In ischaemic stroke the commonest risk factor was tobacco abuse (52%) and the next was hypertension (37%). But in the haemorrhagic strokes the commonest risk factor were hypertension, tobacco abuse and alcohol (All were 66%) The most common neurological findings in ischaemic stroke were altered sensorium and motor dysfunction (Both 63%). The next finding was cranial nerve involvement (53%). In haemorrhagic strokes all patients had altered sensorium. The incidence of infratentorial lesion was more (83%) compared to supratentorial lesion (16%) in haemorrhagic strokes but both are equal incidence (40% each) in case of ischaemic strokes Mortality in ischaemic stroke was 26.3% and in haemorrhagic stroke it was 50%. Improvement was seen in 47.4% of ischaemic and 50% of haemorrhagic strokes.
Twenty five cases of posterior circulation strokes admitted to Medicine and Neurology wards of HSK Hospital & Research Center during period of 12 months (From Jan 2010 to Dec 2010) were studied for incidence, mode of presentation, pattern, clinical manifestations and neurological findings. To the best of our knowledge there are no studies available in posterior circulation haemorrhagic strokes in India in literature, hence we could not compare clinical profile, risks factor and various other parameters of haemorrhagic posterior circulation strokes. The incidence of posterior circulation stroke was 12.3% in the study, which was comparable with other studies conducted by Jones.et al (8) (17%) and Richard et al (5) (14.8%). In the present study the incidence of posterior circulation ischaemic strokes in below 60 years age group was 56% which was more compared to Jones.et al 8 study (22%), this can be explained on the basis that the incidence of stroke in young is more in India compared to western countries. Incidence was more in males compared to females was in accordance with other studies like Ma.Cristina L et al (9) study and R.B.Libman et al (10) study. In the present study incidence of ischaemic strokes was more (76%) compared to haemorrhagic stroke (24%) was in accordance with other studies like Uma Sundar et al (11)(77% ischaemic strokes). Incidence of infratentorial ischaemic strokes was high (63%) compared to other sites in the present study. But the incidence of infratentorial strokes was less compared to Bogousslavsky et al study (12) (70%), this can be explained on the basis that in our study we used only CT scan to identify infratentorial lesion which is a poor diagnostic tool compared to MRI scan. Incidence of acute completed stroke was 53% and step wise in 47% in the present study, which was in accordance with Patrick et al 13 study. In his study incidence was 44% and 56% respectively.Majority of clinical manifestations were comparable to the Patrick et al (13) study. The incidence of visual disturbance was high in present study (47%) compared to Patrick et al study (13) (13%). This was due to presence of more number of occipital infarcts in the present study. (32% Vs. 8%) Incidence of risk factors like hypertension was comparable with the studies by E.Ratnavalli et al (14), Capalan et al (15) , and Uma et al (11). Incidence of alcohol and IHD were same as of E.Ratnavalli et al (14),because study from the same geographic area. Incidence of high tobacco abuse can be explained on the basis that the tobacco abuse is more than this part of state. Majority of neurological findings of present study correlates well with Patrick et al (13) study. Incidence of mortality correlates well with other studies like Patrick et al 13 study (25.6%), Uma et al (11) study (17%) and Jones et al 8 study (27.5%). Incidence of improvement in this study was 47% where as in Jones et al (8)study it was 35%.
The authors wish to thank Dr. C.S. Patil, Principal, S.Nijalingappa
Medical College for his guidance during this study.
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