Posterior Cerebral Artery Stroke Clinical Presentation

  • Author: Christopher Luzzio, MD; Chief Editor: Denise I Campagnolo, MD, MS   more...
 
Updated: Jan 18, 2012
 

History

Patients with posterior cerebral artery (PCA) infarcts present for neurologic evaluation with symptoms including the following:

  • Acute vision loss
  • Confusion[5]
  • New onset posterior cranium headache
  • Paresthesias
  • Limb weakness
  • Dizziness
  • Nausea
  • Memory loss
  • Language dysfunction[6]

Because many individuals identify stroke with motor weakness or language loss, they may delay seeking medical care after experiencing only vision change or headache, unaware that a stroke has occurred.

Patients may report bumping into objects, hitting obstacles on the roadside, or not seeing half the printed page when reading.

  • Small, homonymous visual-field cuts often are mistaken for a loss or change of vision from 1 eye attributable to a refractive error correctable with optical glasses.
  • A person with a hemifield visual loss and headache also may be discharged from urgent care with a diagnosis of migraine headache rather than of PCA stroke. A computed tomography (CT) scan easily can differentiate between both conditions. Additionally, a migraine is characterized by a moving scintillating scotoma, not a fixed bilateral homonymous field cut.
  • The presence of homonymous hemianopia also helps in differentiating between a middle cerebral artery and PCA stroke, as profound hemiplegia or somatosensory loss may occur in both conditions.
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Physical

The most common examination finding is a homonymous visual-field cut, usually a complete hemianopia, caused by a lesion in the contralateral occipital lobe. Macular or central field sparing can occur if the occipital pole remains intact through blood supply from a branch of the middle cerebral artery. Cortical blindness results from bilateral posterior cerebral artery (PCA) infarcts.[4, 7]

  • Deep or proximal PCA infarcts involve portions of the thalamus and midbrain. Thalamic lesions result in contralateral face and limb sensory loss. The midbrain cerebral peduncle carries corticospinal tract fibers that decussate caudally in the brainstem. A peduncle lesion is associated with contralateral motor weakness. Motor symptoms also are induced by thalamic edema near the internal capsule or a focal lesion in this structure. The posterior aspect of the internal capsule, variably, receives some blood from branches off the proximal PCA.
  • Large or bilateral PCA infarcts that involve thalamus, temporal, and/or parietal-occipital lobes often result in a spectrum of possible findings (neuropsychologic deterioration and memory, language, or visual-cognitive dysfunction). Prosopagnosia and visual agnosia are representative examples.
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Causes

Major etiologies of posterior cerebral artery (PCA) infarction include cardiac embolism, vertebrobasilar disease, and PCA atherothrombosis.[8]

  • Vertebrobasilar disease includes atherosclerosis, dissection, and aneurysm, all of which may cause artery-to-artery embolic events. Less frequent causes include paradoxical embolism, migraine, hypotension, hypercoagulable state, and fibromuscular dysplasia.
  • A study by de Monyé et al investigated whether the risk for ischemic stroke is higher in persons who have a PCA with a fetal origin (ie, a PCA that arises directly from the supraclinoid internal carotid artery rather than from the basilar artery).[9] Using 16–multidetector-row CT angiography, the authors studied 82 patients with a PCA infarct and/or isolated homonymous hemianopia. Thirty-two patients had a PCA with a fetal origin, 14 of whom had it on their symptomatic side and 18 of whom had it on their asymptomatic side. The study found no link between the presence of a fetal origin for PCAs and an increased ischemic stroke risk in the territory of the PCA.
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Contributor Information and Disclosures
Author

Christopher Luzzio, MD  Clinical Assistant Professor, Department of Neurology, University of Wisconsin at Madison School of Medicine and Public Health

Christopher Luzzio, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Coauthor(s)

Consuelo T Lorenzo, MD  Physiatrist, Department of Physical Medicine and Rehabilitation, Alegent Health Immanuel Rehabilitation Center

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Elizabeth A Moberg-Wolff, MD  Medical Director, Pediatric Rehabilitation Medicine Associates

Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation

Disclosure: Medtronic Neurological None Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard Salcido, MD  Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS  Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers

Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers

Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds investigator; Novartis investigator; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

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Computed tomography (CT) scan of the brain showing hypodense areas in the right occipital lobe consistent with a recent posterior cerebral artery ischemic infarct.
 
 
 
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