Diagnostic Considerations

The usual differential diagnosis for posterior cerebral artery (PCA) stroke includes other vascular diseases such as intracerebral hemorrhage, cerebral venous infarction, subarachnoid hemorrhage, and subdural hemorrhage. Rarely, space-occupying lesions (eg, glioma) present as sudden onset of deficit.

Demyelinating lesions (eg, multiple sclerosis) rarely present as hemianopia, but this does occur in a few patients. Posterior reversible encephalopathy syndrome may present with visual disturbances and imaging abnormalities within the occipital lobes.

Conditions to consider in the differential diagnosis of PCA stroke include the following:

Basilar artery thrombosis
Cardioembolic stroke
Dissection syndromes
Intracranial hemorrhage
Mitochondrial encephalomyopathy, lactic acidosis, strokelike episodes (MELAS)
Multiple sclerosis
Brain metastases
Trauma
Infection
Cardiac embolism
Brainstem infarction

Differential Diagnoses

Chronic Pain Syndrome
Lacunar Stroke
Middle Cerebral Artery Stroke
Migraine Headache
Multiple Sclerosis
Posterior reversible encephalopathy syndrome
Subarachnoid Hemorrhage
Subdural Hematoma
Systemic Lupus Erythematosus (SLE)
Vascular Diseases and Rehabilitation
Vertebrobasilar Stroke

Workup

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Media Gallery

Unenhanced head computed tomography (CT) scan demonstrating a subacute L posterior cerebral artery (PCA) infarct.
Unenhanced head computed tomography (CT) scan demonstrating hemorrhagic conversion of an ischemic stroke, approximately 72 hours after symptom onset.
Brain magnetic resonance imaging (MRI) scan demonstrating acute stroke. Diffusion restriction is seen on diffusion-weighted imaging.
Magnetic resonance (MR) angiogram demonstrating bilateral fetal posterior cerebral artery (PCA) variants (black arrows) with the basilar artery terminating in bilateral superior cerebellar arteries (blue arrows).
Digital subtraction angiogram demonstrating an acute L posterior cerebral artery (PCA) occlusion (red arrow) following balloon-assisted coiling of a basilar tip aneurysm.
Digital subtraction angiogram demonstrating revascularization of acute L posterior cerebral artery (PCA) occlusion (red arrow) during a balloon-assisted basilar tip aneurysm revascularization with use of balloon angioplasty.
Computed tomography (CT) scan of the brain showing hypodense areas in the right occipital lobe consistent with a recent posterior cerebral artery (PCA) ischemic infarct.

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Author

Erek K Helseth, MD Vascular and Interventional Neurologist, Vascular Neurology SoCal

Erek K Helseth, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Acknowledgements

Alastair M Buchan, DSc, MBBCh Professor, Head of Medical Sciences Division, University of Oxford, UK