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Posterior circulation cerebrovascular syndromes

INTRODUCTION

Twenty percent of ischemic events in the brain involve posterior circulation (vertebrobasilar) structures. This topic will review the major clinical syndromes associated with posterior circulation ischemia that is caused by stenosis or occlusion of the large aortic arch, neck, and intracranial arteries. These arteries are the innominate and subclavian arteries in the chest, the vertebral arteries in the neck, and the intracranial vertebral, basilar, and posterior cerebral arteries.

The evaluation and management of acute ischemic stroke (including stroke involving the posterior circulation) is discussed separately. (See "Initial assessment and management of acute stroke" and "Fibrinolytic (thrombolytic) therapy for acute ischemic stroke" and "Neuroimaging of acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke".)

SOURCE OF ISCHEMIA

The most common causes of posterior circulation large artery ischemia are atherosclerosis, embolism, and dissection. Dolichoectasia (elongation and tortuosity) of the vertebral and basilar arteries is another occasional cause.

  • About one-third of posterior circulation strokes are caused by occlusive disease within the large neck and intracranial arteries, which are the vertebral arteries in the neck and the intracranial vertebral, basilar, and posterior cerebral arteries [1-4].
  • The proximal portion of the vertebral artery in the neck is the most common location of atherosclerotic occlusive disease within the posterior circulation [1-5]. Atherosclerosis of the intracranial vertebral arteries (ICVAs) and of the basilar artery is also common. (See "Intracranial large artery atherosclerosis".)

  • Dissection of the extracranial vertebral arteries (ECVAs) and ICVAs is another frequent cause of ischemia within the posterior circulation.
  • Unlike the vertebral and basilar arteries, atherosclerosis and dissection of the posterior cerebral arteries (PCAs) is not common. Most PCA territory infarcts are due to embolism from the heart, aorta, or vertebral arteries.
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