eMedicine Specialties > Neurology > Neuro-vascular Diseases

Posterior Cerebral Artery Stroke: Differential Diagnoses & Workup

Author: Michael D Hill, MD, Medical Director, Stroke Unit, Associate Professor of Neurology, Department of Clinical Neurosciences, Foothills Hospital, University of Calgary, Canada
Coauthor(s): Alastair M Buchan, DSc, MB, BCh, Professor, Head of Medical Sciences Division, University of Oxford, UK
Contributor Information and Disclosures

Updated: Nov 10, 2009

Differential Diagnoses

Acute Disseminated Encephalomyelitis
HIV-1 Associated Cerebrovascular Complications
Acute Stroke Management
Intracranial Hemorrhage
Amyloid Angiopathy
Low-Grade Astrocytoma
Aphasia
Meningioma
Arteriovenous Malformations
Metabolic Disease & Stroke: MELAS
Basilar Artery Thrombosis
Migraine Headache
Blood Dyscrasias and Stroke
Migraine Headache: Neuro-Ophthalmic Perspective
Brainstem Gliomas
Migraine Variants
Cardioembolic Stroke
Multiple Sclerosis
Carotid Ultrasound
Polyarteritis Nodosa
Cerebellar Hemorrhage
Posterior Cerebral Artery Stroke
Cerebral Venous Thrombosis
Stroke Anticoagulation and Prophylaxis
Cocaine
Subarachnoid Hemorrhage
Complex Partial Seizures
Subdural Hematoma
Dissection Syndromes
Glioblastoma Multiforme

Other Problems to Be Considered

Hypoglycemia
Venous infarction
Carotid disease and stroke

Workup

Laboratory Studies

  • In the acute phase, routine blood tests are all that is needed. These include a complete blood count (with platelet count), prothrombin time (PT)/activated partial thromboplastin time (aPTT)/international normalized ratio (INR), electrolytes, creatinine, serum creatine kinase (CK), and serum glucose. These tests are required to assess whether the patient is a candidate for thrombolysis and are a part of the stroke mechanism workup.
  • If the stroke mechanism is not evident on the basis of imaging studies, then special hematologic and serologic examinations should be ordered. A full coagulation workup typically might include assays for antiphospholipid antibodies and lupus anticoagulant. Hypercoagulable factors usually associated with venous infarction, such as protein C, protein S, factor V Leiden-activated protein C resistance, antithrombin III, and prothrombin gene polymorphism, may be appropriate if the stroke mechanism is thought to involve either venous thrombosis or paradoxical embolism. These tests are better done 2-3 weeks after the acute event. Blood smear examination, platelet aggregation studies, sucrose lysis test for paroxysmal nocturnal hemoglobinuria, and Venereal Disease Research Laboratory test (VDRL) also should be considered. Abnormalities in any of these blood tests are rare causes of stroke. Nevertheless, particularly in a young patient, a full workup should be considered.
  • When the mechanism of stroke is atherosclerotic disease, follow-up blood tests should be done to assess atherosclerotic risk factors. Diabetes should be considered and screened for. A fasting serum cholesterol profile may be artifactually low in the acute setting and should therefore be conducted 8-12 weeks after the stroke. High cholesterol is a definite risk factor for stroke and is amenable to treatment.
  • In selected patients, assessing fasting serum homocysteine levels is reasonable. High serum homocysteine level is an independent risk factor for all atherosclerotic disease and may be treated with simple B complex vitamins—pyridoxine, folic acid, and vitamin B-12. A large, randomized trial of vitamin supplementation for stroke prevention is currently underway. This study is entitled Vitamin Intervention in Stroke Prevention or VISP.

Imaging Studies

  • Neuroimaging: All patients with stroke should undergo neuroimaging, either with the traditional brain CT scan or MRI with diffusion and perfusion imaging (see Media file 1).

  • Posterior cerebral artery (PCA) stroke. Subacute ...

    Posterior cerebral artery (PCA) stroke. Subacute (36 hour) infarction of the left PCA territory.

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    Posterior cerebral artery (PCA) stroke. Subacute ...

    Posterior cerebral artery (PCA) stroke. Subacute (36 hour) infarction of the left PCA territory.

  • An emergent CT scan is required prior to considering thrombolysis. CT is less sensitive for the posterior fossa strokes because of bone artifact and decreased tissue detail. MRI is a better choice.
  • MRI defines multiple lesions and allows a much better examination of midbrain, subthalamic, and thalamic structures than CT scan. With the use of diffusion- and perfusion-weighted imaging, a much more complete assessment of the infarcted tissue and tissue at risk is available.
  • Other possible brain imaging procedures include single-photon emission computed tomography (SPECT) and positron emission tomography (PET).
    • SPECT is a nuclear medicine study using radioisotopes of technetium. It provides an analysis of relative blood flow by region, usually in the resting state. It is rarely useful in the clinical setting in acute stroke and can be considered a research tool.
    • PET can be used to analyze neurometabolism in vivo; it is at present a research tool.
  • Rarely, plain skull films demonstrate an unexpected tumor or calcification in an aneurysm.
  • Transcranial Doppler ultrasonography (TCD) is not yet widely used and remains largely a research tool; however, that it is a highly useful adjunct in the emergent evaluation of patients with stroke is becoming increasingly apparent. TCD is dependent upon the skill and experience of the operator. In skilled hands, both the distal basilar and P1 and P2 segments can be assessed. Much more information is available about the MCA than the PCA. However, TCD may detect acute clot in the PCA.
  • Carotid duplex ultrasonography is used widely and should not be overlooked in PCA stroke. When a fetal origin PCA is present, the cause of stroke still may be significant carotid artery atherosclerotic disease. The appropriate treatment for secondary prevention will then be carotid endarterectomy rather than medical therapy.
  • Selective catheter cerebral angiography remains the criterion standard to evaluate the vascular anatomy. However, it is invasive and does carry a small risk of procedure-related morbidity. Increasingly, noninvasive methods of viewing the arterial anatomy are being developed—magnetic resonance angiography, CT angiography (CTA), and TCD. Currently these tests are reasonably good for assessment of the proximal circulation. When these are doubtful or more information is needed about the distal circulation, angiography is required. Angiography is needed to diagnose small aneurysms or vasculitis. In addition, angiography is required as a precursor to endovascular therapeutic techniques. Angioplasty and angioplasty with stenting are being adapted to the cerebral circulation. Presently, these techniques should be considered experimental.
  • Echocardiography: Standard transthoracic echocardiography (TTE) is used in investigation of possible cardiac sources of embolus. This noninvasive test is done routinely in most tertiary care centers. Transesophageal echocardiography (TEE) is a more detailed test and is used to examine the aortic arch as well as cardiac sources of emboli. It is about 3 times more sensitive than TTE in detecting possible sources of emboli. A recent study suggested that it is cost-effective in acute stroke, whereas the TTE is not, despite the greater cost of TEE.

Other Tests

All patients with stroke should have an immediate ECG.

More on Posterior Cerebral Artery Stroke

Overview: Posterior Cerebral Artery Stroke
Differential Diagnoses & Workup: Posterior Cerebral Artery Stroke
Treatment & Medication: Posterior Cerebral Artery Stroke
Follow-up: Posterior Cerebral Artery Stroke
Multimedia: Posterior Cerebral Artery Stroke
References
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References

  1. Yamamoto Y, Georgiadis AL, Chang HM, Caplan LR. Posterior cerebral artery territory infarcts in the New England Medical Center Posterior Circulation Registry. Arch Neurol. Jul 1999;56(7):824-32. [Medline].

  2. Caplan LR, Amarenco P, Rosengart A, et al. Embolism from vertebral artery origin occlusive disease. Neurology. Aug 1992;42(8):1505-12. [Medline].

  3. NINDS and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. Dec 14 1995;333(24):1581-7. [Medline].

  4. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. Sep 25 2008;359(13):1317-29. [Medline].

  5. Wahlgren N, Ahmed N, Davalos A, Hacke W, Millan M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. Oct 11 2008;372(9646):1303-9. [Medline].

  6. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. Aug 2009;40(8):2945-8. [Medline]. [Full Text].

  7. TOAST Investigators. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. JAMA. Apr 22-29 1998;279(16):1265-72. [Medline].

  8. Adams HP, Bendixen BH, Leira E, et al. Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. Jul 13 1999;53(1):122-5. [Medline].

  9. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. Dec 1 1994;331(22):1474-9. [Medline].

  10. Amarenco P, Duyckaerts C, Tzourio C, et al. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med. Jan 23 1992;326(4):221-5. [Medline].

  11. Ausman JI, Diaz FG, de los Reyes RA, et al. Anastomosis of occipital artery to anterior inferior cerebellar artery for vertebrobasilar junction stenosis. Surg Neurol. Aug 1981;16(2):99-102. [Medline].

  12. Ausman JI, Lee MC, Chater N, Latchaw RE. Superficial temporal artery to superior cerebellar artery anastomosis for distal basilar artery stenosis. Surg Neurol. Oct 1979;12(4):277-82. [Medline].

  13. Ausman JI, Nicoloff DM, Chou SN. Posterior fossa revascularization: anastomosis of vertebral artery to PICA with interposed radial artery graft. Surg Neurol. May 1978;9(5):281-6. [Medline].

  14. Barnett HJM, Mohr JP, Stein BM. Stroke. 3rd ed. New York: Churchill Livingstone;1998.

  15. Bennett CL, Davidson CJ, Raisch DW, et al. Thrombotic thrombocytopenic purpura associated with ticlopidine in the setting of coronary artery stents and stroke prevention. Arch Intern Med. Nov 22 1999;159(21):2524-8. [Medline].

  16. Bennett CL, Weinberg PD, Rozenberg-Ben-Dror K, et al. Thrombotic thrombocytopenic purpura associated with ticlopidine. A review of 60 cases. Ann Intern Med. Apr 1 1998;128(7):541-4. [Medline].

  17. Broderick JP, Swanson JW. Migraine-related strokes. Clinical profile and prognosis in 20 patients. Arch Neurol. Aug 1987;44(8):868-71. [Medline].

  18. Buchan AM, Barber PA, Newcommon N, et al. Effectiveness of t-PA in acute ischemic stroke: outcome relates to appropriateness. Neurology. Feb 8 2000;54(3):679-84. [Medline].

  19. Caplan LR, DeWitt LD, Pessin MS, et al. Lateral thalamic infarcts. Arch Neurol. Sep 1988;45(9):959-64. [Medline].

  20. Carpenter MB. Core Text of Neuroanatomy. 4th ed. Baltimore, Md: Williams and Wilkins;1991.

  21. Chambers BR, Brooder RJ, Donnan GA. Proximal posterior cerebral artery occlusion simulating middle cerebral artery occlusion. Neurology. Mar 1991;41(3):385-90. [Medline].

  22. Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA. Dec 1 1999;282(21):2019-26. [Medline].

  23. Devinsky O, Bear D, Volpe BT. Confusional states following posterior cerebral artery infarction. Arch Neurol. Feb 1988;45(2):160-3. [Medline].

  24. Dorfman LJ, Marshall WH, Enzmann DR. Cerebral infarction and migraine: clinical and radiologic correlations. Neurology. Mar 1979;29(3):317-22. [Medline].

  25. Duncan GW, Weindling SM. Posterior cerebral artery stenosis with midbrain infarction. Stroke. May 1995;26(5):900-2. [Medline].

  26. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. Dec 1 1999;282(21):2003-11. [Medline].

  27. Georgiadis AL, Yamamoto Y, Kwan ES, et al. Anatomy of sensory findings in patients with posterior cerebral artery territory infarction. Arch Neurol. Jul 1999;56(7):835-8. [Medline].

  28. Gomori AJ, Hawryluk GA. Visual agnosia without alexia. Neurology. Jul 1984;34(7):947-50. [Medline].

  29. Grond M, Stenzel C, Schmulling S, et al. Early intravenous thrombolysis for acute ischemic stroke in a community-based approach. Stroke. Aug 1998;29(8):1544-9. [Medline].

  30. Grotta J, Bratina P. Subjective experiences of 24 patients dramatically recovering from stroke. Stroke. Jul 1995;26(7):1285-8. [Medline].

  31. Gustafsson D, Elg M. The pharmacodynamics and pharmacokinetics of the oral direct thrombininhibitor ximelagatran and its active metabolite melagatran: amini-review. Thromb Res. Jul 15 2003;109 Suppl 1:S9-15. [Medline].

  32. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. Oct 17 1998;352(9136):1245-51. [Medline].

  33. Hill MD, Barber PA, Takahashi J, et al. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke. CMAJ. May 2 2000;162(9):1281-4. [Medline].

  34. Hill MD, Hachinski V. Stroke treatment: time is brain. Lancet. Oct 1998;352 Suppl 3:SIII10-4. [Medline].

  35. Hommel M, Besson G, Pollak P, et al. Hemiplegia in posterior cerebral artery occlusion. Neurology. Oct 1990;40(10):1496-9. [Medline].

  36. Hommel M, Moreaud O, Besson G, Perret J. Site of arterial occlusion in the hemiplegic posterior cerebral artery syndrome. Neurology. Apr 1991;41(4):604-5. [Medline].

  37. International Stroke Trial Collaborative Group. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet. May 31 1997;349(9065):1569-81. [Medline].

  38. Johansson T, Fahlgren H. Alexia without agraphia: lateral and medial infarction of left occipital lobe. Neurology. Mar 1979;29(3):390-3. [Medline].

  39. Klinkel WR, Newman RP, Jacobs L. Posterior cerebral artery branch occlusions: CT and anatomic considerations. In: Berguer R, Bauer RB, eds. Vertebrobasilar Arterial Occlusive Disease: Medical and Surgical Management. Proceedings of the First International Conference on Vertebrobasilar. New York: Raven Press;. 1984.

  40. Koroshetz WJ, Ropper AH. Artery-to-artery embolism causing stroke in the posterior circulation. Neurology. Feb 1987;37(2):292-5. [Medline].

  41. Kumral E, Bayulkem G, Atac C, Alper Y. Spectrum of superficial posterior cerebral artery territory infarcts. Eur J Neurol. Apr 2004;11(4):237-46. [Medline].

  42. Levine DN, Rinn WE. Opticosensory ataxia and alien hand syndrome after posterior cerebral artery territory infarction. Neurology. Aug 1986;36(8):1094-7. [Medline].

  43. Marinkovic SV, Milisavljevic MM, Kovacevic MS. Anastomoses among the thalamoperforating branches of the posterior cerebral artery. Arch Neurol. Aug 1986;43(8):811-4. [Medline].

  44. Moen M, Levine SR, Newman DS. Bilateral posterior cerebral artery strokes in a young migraine sufferer. Stroke. Apr 1988;19(4):525-8. [Medline].

  45. Mohr JP, Leicester J, Stoddard LT, Sidman M. Right hemianopia with memory and color deficits in circumscribed left posterior cerebral artery territory infarction. Neurology. Nov 1971;21(11):1104-13. [Medline].

  46. Mohr JP, Pessin MS. Posterior Cerebral Artery Disease. 3rd ed. New York: Churchill Livingstone;1998.

  47. Neau JP, Bogousslavsky J. The syndrome of posterior choroidal artery territory infarction. Ann Neurol. Jun 1996;39(6):779-88. [Medline].

  48. North K, Kan A, de Silva M, Ouvrier R. Hemiplegia due to posterior cerebral artery occlusion. Stroke. Nov 1993;24(11):1757-60. [Medline].

  49. Percheron G. [Arteries of the human thalamus. I. Artery and polar thalamic territory of the posterior communicating artery]. Rev Neurol (Paris). May 1976;132(5):297-307. [Medline].

  50. Percheron G. [Arteries of the human thalamus. II. Arteries and paramedian thalamic territory of the communicating basilar artery]. Rev Neurol (Paris). May 1976;132(5):309-24. [Medline].

  51. Pessin MS, Kwan ES, DeWitt LD, Hedges TR 3rd. Posterior cerebral artery stenosis. Ann Neurol. Jan 1987;21(1):85-9. [Medline].

  52. Pessin MS, Kwan ES, Scott RM, Hedges TR 3rd. Occipital infarction with hemianopsia from carotid occlusive disease. Stroke. Mar 1989;20(3):409-11. [Medline].

  53. Pessin MS, Lathi ES, Cohen MB, et al. Clinical features and mechanism of occipital infarction. Ann Neurol. Mar 1987;21(3):290-9. [Medline].

  54. Piechowski-Jozwiak B, Bogousslavsky J. Basilar occlusive disease: the descent of the feared foe?. Arch Neurol. Apr 2004;61(4):471-2. [Medline].

  55. Pillon B, Bakchine S, Lhermitte F. Alexia without agraphia in a left-handed patient with a right occipital lesion. Arch Neurol. Dec 1987;44(12):1257-62. [Medline].

  56. Sharis PJ, Cannon CP, Loscalzo J. The antiplatelet effects of ticlopidine and clopidogrel. Ann Intern Med. Sep 1 1998;129(5):394-405. [Medline].

  57. Sherman DG, Atkinson RP, Chippendale T, et al. Intravenous ancrod for treatment of acute ischemic stroke: the STAT study: a randomized controlled trial. Stroke Treatment with Ancrod Trial. JAMA. May 10 2000;283(18):2395-403. [Medline].

  58. Stommel EW, Friedman RJ, Reeves AG. Alexia without agraphia associated with spleniogeniculate infarction. Neurology. Apr 1991;41(4):587-8. [Medline].

  59. Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists' Collaboration. BMJ. Apr 19 1997;314(7088):1151-9. [Medline].

  60. Tanne D, Bates VE, Verro P, et al. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group. Neurology. Jul 22 1999;53(2):424-7. [Medline].

  61. Tatemichi TK, Steinke W, Duncan C, et al. Paramedian thalamopeduncular infarction: clinical syndromes and magnetic resonance imaging. Ann Neurol. Aug 1992;32(2):162-71. [Medline].

  62. The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. N Engl J Med. Nov 7 1985;313(19):1191-200. [Medline].

  63. Zweifler RM. Management of acute stroke. South Med J. Apr 2003;96(4):380-5. [Medline].

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Further Reading

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Keywords

stroke, posterior cerebral artery stroke, vertebrobasilar insufficiency, posterior circulation stroke, PCA, PCA stroke, ischemic stroke, embolization, intrinsic atherosclerotic disease and vasospasm, migrainous strokes, PCA syndromes, paramedian thalamic infarction, cardioembolism

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Contributor Information and Disclosures

Author

Michael D Hill, MD, Medical Director, Stroke Unit, Associate Professor of Neurology, Department of Clinical Neurosciences, Foothills Hospital, University of Calgary, Canada
Michael D Hill, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Neurology, American College of Physicians, American Stroke Association, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Hoffmann La Roche Canada Ltd Honoraria Speaking and teaching

Coauthor(s)

Alastair M Buchan, DSc, MB, BCh, Professor, Head of Medical Sciences Division, University of Oxford, UK
Disclosure: Nothing to disclose.

Medical Editor

Thomas A Kent, MD, Professor, Department of Neurology, Baylor College of Medicine; Neurology Care Line Executive, Michael E DeBakey Veterans Affairs Medical Center
Thomas A Kent, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences, Royal Society of Medicine, Sigma Xi, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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