Left Posterior Cerebral Artery Territory Research Articles

Abstract 104: Fetal Posterior Cerebral Artery (PCA) Occlusion from Occluded Cavernous ICA Stent

Introduction Posterior Cerebral Artery (PCA) is a medium vessel occlusion (MVO) which is 5‐10% of all acute ischemic events. Safety and efficacy of mechanical thrombectomy in posterior circulation MVO is unclear compared to medical treatment only (1). There is concern that fragility of distal, smaller vessels may have an increased risk of procedural complications (e.g., arterial dissection and or perforations). More people are getting flow divertors over the years and rate of flow diverter of ICA occlusion is 0.05%‐0.08% (2). Here we present a case of embolic fetal PCA stroke with ICA stent occlusion. Methods We report a case of fetal origin posterior cerebral artery occlusion from ICA with literature search of Pubmed. Results 77 years old female with left cavernous‐ICA stent presented from a rehab facility with complaints of word finding difficulty, confusion, right hemiparesis, right sided neglect, and visual disturbance. In the emergency department (ED), her NIHSS was 28. ED presentation was 2.5 hrs after the last known well (LKW). Of note, patient had a with left cavernous‐ICA stent placement a month before the presentation and was noncompliant to antiplatelets. CT head was negative for intracranial bleeding and ASPECT score was 7. CT angiography head and neck was obtained, showing new complete interval occlusion of the intracranial extradural left ICA with reconstitution of distal branches through anterior communicating artery. Patient received IV thrombolytics, intubated for airway protection and was transferred to a comprehensive stroke center for possible mechanical thrombectomy. Time of the arrival was approximately 6 hours after the LKW, reexamination was hindered by the sedation and intubation but was concerning for possible PCA occlusion rather than ICA occlusion. As the localization of ischemic area was unclear, CT perfusion (CTP) was obtained. CTP showed 27 ml penumbra without core infarct in left PCA territory. As fetal origin of left PCA from ICA is occluded, without ability to access through occluded stent, noted risk of left ICA complications with attempts to recanalize stent for noted PCA hypoperfusion outweigh the benefits. With the exam improvement post thrombolytics administration and small penumbra, mechanical thrombectomy was not indicated. Conclusion In acute large vessel occlusion, utility of CT perfusion (CTP) usually recommended after 6 hours from last well known. In this case, patient presented within the 6 hours but the reexamination post thrombolytics was not localizing to suggest large vessel occlusion (LVO) and the territory at risk was unclear. We described a left intracranial ICA flow diversion occlusion without anterior circulation ischemia and left PCA ischemia demonstrated. In this case, CTP was employed to differentiate the territory at risk for triage to appropriate intervention, to differentiate the LVO vs MVO.

Memory, Executive, and Intellectual Functions in Adults with Moyamoya Disease

Cognitive function can decline in adults with moyamoya disease (MMD). Memory, which is an essential but complex and multifaceted function, underpins executive and intellectual functions. However, the relationship between memory and executive or intellectual functions in adults with MMD has not been well studied. The relationship between memory and cerebral blood flow has also not been elucidated. This study investigated correlations between memory, executive function, and intellectual function, and associations between cerebral blood flow and memory in adults with MMD. Memory, executive function, and intellectual function were assessed using the Wechsler Memory Scale-Revised (WMS-R), Frontal Assessment Battery (FAB), and Wechsler Adult Intelligence Scale (WAIS) third or fourth edition, respectively, in 31 adults with MMD. Cerebral blood flow was measured with iodine 123I-iodoamphetamine single-photon emission computed tomography. WMS-R scores correlated significantly with total FAB and WAIS scores before and after revascularization. Cerebral blood flow in the left posterior cerebral artery territory correlated positively with WMS-R and WAIS scores pre- and postoperatively. Postoperative cerebrovascular reserves of the right cerebellum, pons, and vermis were positively associated with visual memory, and postoperative cerebrovascular reserve of the pons was also associated with general memory. Memory function correlates with executive and intellectual functions in adults with MMD. The FAB, which requires about 10min to administer, might be useful to screen for memory dysfunction. Memory might be vulnerable to hypoperfusion in the posterior cerebral artery territory among adults with MMD. Postoperative cerebrovascular reserve might help predict memory dysfunction in adults with MMD.

Thrombotic Thrombocytopenic Purpura (ADAMTS13 [a Disintegrin and Metalloproteinase With a Thrombospondin Type 1 Motif, Member 13] Deficiency) as Cause of Recurrent Multiterritory Ischemic Strokes.

Thrombotic Thrombocytopenic Purpura (ADAMTS13 [a Disintegrin and Metalloproteinase With a Thrombospondin Type 1 Motif, Member 13] Deficiency) as Cause of Recurrent Multiterritory Ischemic Strokes.

Premorbid language function: a prognostic factor for functional outcome in aphasia?

ABSTRACT Background Stroke lesion size and location are understood to be more accurate predictors of recovery from aphasia than demographic variables such as age, education, or socioeconomic status. Aims We hypothesise that markedly high premorbid language function can influence functional recovery from aphasia. Methods & Procedures This case study reports the recovery of a 64-year-old right-handed male, with large left posterior cerebral artery territory infarct involving the thalamus, occipital lobe and posteromedial temporal lobe. The report is informed by retrospective review of clinical notes, language assessment, and interviews with the participant and his family. Premorbidly, he had acquired fluency in five additional languages in early adulthood, followed by a career in senior roles within corporate communications. Outcomes & Results Following severe expressive aphasia in the acute period, the subacute and chronic phases were characterised by residual mild anomia and cognitive communication difficulties apparent on formal assessment, yet masked in functional contexts through compensatory strategies and preservation of an authoritative premorbid communication style. Conclusions The current report provides single-case evidence that individuals with markedly high premorbid metalinguistic skills may, in functional contexts, be able to compensate for expressive aphasic deficits and preserve their communicative competence. The discrepancy between the participant’s performance on formal versus informal language assessment underscores the necessity for both perspectives for accurate diagnosis of aphasia. Consideration of premorbid language function can usefully guide clinical decision-making about intervention for individuals with aphasia.

A case of diabetic ketoacidosis with posterior cerebral artery territory ischemic stroke mimicking uncal herniation

In diabetic ketoacidosis, hyperglycemia and ketosis result in cerebral vasculitis, which can cause cerebral edema and thrombosis. A previously healthy, 12-year-old girl visited the emergency department with a history of vomiting, polydipsia, polyuria, decreased mentality, and a 7 kg (12%) weight loss within 1 week. She showed laboratory features of severe diabetic ketoacidosis, stuporous mentality, respiratory failure, and unilateral fixed mydriasis with contralateral hemiparesis. However, brain magnetic resonance imaging showed multifocal ischemic stroke mainly involving the left posterior cerebral artery territory, instead of uncal herniation. This case highlights the possible occurrence of ischemic stroke in children with early-stage diabetes mellitus. Key Words: Cerebral Infarction; Child; Diabetic Ketoacidosis; Infarction, Posterior Cerebral Artery; Stroke; Vasculitis, Central Nervous System

Optimal Imaging at the Primary Stroke Center.

Optimal Imaging at the Primary Stroke Center.

Abstract 18462: Hickam's Dictum Revisited: A Multifactorial Etiology of Stroke in a Patient With Rheumatic Mitral Stenosis and Atrial Septal Aneurysm

A 64-year-old gentleman with rheumatic mitral stenosis (MS), coronary artery disease, and active tobacco abuse was admitted with a left posterior cerebral artery (PCA) territory ischemic cerebrovascular accident (CVA). He presented with confusion, headaches, and alexia with stable vital signs. He denied rest or exertional dyspnea. Physical exam revealed right homonymous hemianopia, mild right upper extremity dysmetria, decreased right facial sensation, and mild prosopagnosia. Initial neuroimaging confirmed an evolving left hemispheric infarct. Laboratory testing showed unremarkable inflammatory markers. Computed tomographic (CTA) and magnetic resonance angiography (MRA) of the head and neck confirmed left PCA territory acute or subacute infarction with occlusion of the left P2 segment. 12-lead electrocardiogram demonstrated normal sinus rhythm. Occult atrial fibrillation was not seen. Transthoracic echocardiogram (TTE) showed no evidence of right-to-left interatrial shunt. Moderate left atrial (LA) dilation, posterior mitral leaflet tip calcification, and a resting mean mitral gradient of 20 millimeters of mercury (mmHg) suggested severe mitral stenosis. Given the discrepancy between the patient’s symptoms and the TTE findings, transesophageal echocardiogram (TEE) was performed (Figure). The patient’s left PCA territory infarct was ascribed to multifactorial cardioembolic etiologies: 1) Atrial septal aneurysm (ASA) 2) Rheumatic MS and 3) Aortic arch atheroma. Anticoagulation was recommended and initiated 14 days after his CVA to minimize risk of hemorrhagic transformation. High-dose atorvastatin and aspirin were instituted. He progressed well through rehabilitation, demonstrating steady neurological improvement. The case underscores the importance of pursuing further investigation when discrepancies exist between clinical and objective data. ASA is an uncommon but under-recognized risk factor for cardioembolic stroke.

Rare cause of myocardial infarction, stroke, and lung tumour

In a 53-year-old male admitted with acutely developing symptoms of right-sided hemiparesis and dysarthria revealed an extensive ischaemic infarct involving the left posterior cerebral artery territory. ECG showed right bundle branch block and significant anterior ST-segment elevation ( Panel A ). In addition, elevated cardiac enzyme levels suggested acute myocardial infarction (MI). Immediate transthoracic echocardiography showed a homogenous mass involving …

Alien hand syndrome in left posterior stroke

Alien hand syndrome is a rare neurological disorder characterized by involuntary and uncontrollable motor behaviour, usually of an arm or hand. The patient perceives the affected limb as alien, and may personify it. The case of a 61-year-old right-handed woman who developed right posterior AHS after ischaemic stroke in the left posterior cerebral artery territory is reported. Neuroimaging studies disclosed no frontal or parietal involvement, while a posterior thalamic lesion was detected. A possible role of the thalamus in the genesis of AHS is discussed.

Early stent thrombosis with progressive brainstem infarction in a clopidogrel non-responder

Nonor hypo-response to clopidogrel has been observed frequently in patients with cardiovascular disease resulting in worsened cardiovascular outcome and a higher complication rate after coronary stenting [1, 2]. However, relevance of a clopidogrel non-response for the incidence of cerebrovascular events as well as for adverse events after supraaortic stenting is unclear. This case illustrates the risk of severe complications associated with a clopidogrel nonresponse for patients receiving intracranial stent-angioplasty and argues for peri-interventional monitoring of clopidogrel induced platelet inhibition and modified treatment in hypo-responders. A 68-year old male patient was admitted to our hospital 12 h after onset of progressing neurological symptoms including dysarthria, a left-sided facial paresis and a rightsided hemiparesis. Cranial MRI and MR angiography revealed an acute ischemic lesion in the left anteriormedial upper medulla oblongata, old infarctions (left cerebellum, right basal ganglia), white matter microangiopathy and stenoses in the V4-segment of the left vertebral artery (LVA) and the basilar artery (BA). Conventional cerebral angiography confirmed a high-grade stenosis of the LVA’s distal V4-segment and moderate stenoses of the proximal V4-segment and the BA’s mid-section as probable causes of acute brainstem infarction (Fig. 1). With clinical symptoms progressing, we decided for endovascular therapy. After deployment of a 4 mm 9 2 cm ‘‘Wingspan ’’stent reaching from the LVA to the BA with subsequent dilatation (3.5 mm Maverick balloon, balloon inflation by slowly increasing pressure to 6 atm) we observed regular flow (TIMI 3) in these vessels (Fig. 1). Medication at admission had included acetylsalicylic acid (ASA; 100 mg/d); during intervention the patient received heparin (ACT 200–300 s), 500 mg ASA and weightadjusted standard dose tirofiban intravenously. After stenting clopidogrel was added (loading dose: 300 mg; subsequent daily dose: 75 mg). Tirofiban was terminated 6 h after clopidogrel loading, ASA (100 mg/d) and enoxaparin (40 mg/d subcutaneously) were continued. Control MRI upon worsening of clinical symptoms (tetraparesis, anarthria) 1 day after stenting revealed increased medulla oblongata infarction, new paramedian infarction of the right pons (Fig. 1) and new small infarcts within the cerebellum and the left posterior cerebral artery territory. Invisibillity of the LVA in the MR angiography was attributed to stent artefact. The patient had to be intubated after developing sepsis with respiratory and partial renal failure. Transcranial ultrasound examination 5 days after stenting revealed reduced flow in the V2-segment and no flow in the LVA’s V3and V4-segment suggesting an in-stent thrombosis. Another MRI control demonstrated progressive brainstem infarction with new pontine and medullar lesions (Fig. 1). Cerebral angiography confirmed stent occlusion in the V4-segment (Fig. 1) with sufficient BA perfusion via the right VA (not shown). Analysing the patient’s platelet inhibition using impedance aggregometry (Multiple Platelet Function Analyzer, J. Weise (&) O. W. Witte Department of Neurology, University of Jena Medical School, Erlanger Allee 101, 07747 Jena, Germany e-mail: jens.weise@med.uni-jena.de

Circuitous embolic hemorrhagic stroke: carotid pseudoaneurysm to fetal posterior cerebral artery conduit: a case report.

IntroductionThe cervical internal carotid artery (ICA) is susceptible to injury through various mechanisms, including dissection, which can lead to pseudoaneurysm formation. Pathological processes affecting the ICA, in association with an ipsilateral fetal posterior cerebral artery (PCA), resulting in parieto-occipital strokes are rarely reported.Case PresentationWe present a patient with a left PCA territory, presumably embolic, stroke with early hemorrhagic transformation. The identified nidus of the embolus was a carotid artery pseudoaneurysm. Manifestations included right homonymous hemianopsia with right hemiparesis and hemisensory loss.ConclusionOur case is unique, and of clinical interest, because it illustrates both the potential anterior-posterior circulation conduit provided by a fetal origin PCA as well as the apparent early hemorrhagic transformation of embolic infarcts that can lead to further confusion from a mechanistic standpoint.

Ruptured Anterior Communicating Artery Aneurysm Causing Bilateral Oculomotor Nerve Palsy : A Case Report

A rare case of bilateral third cranial nerve palsy due to a ruptured anterior communicating artery aneurysm is presented. A 68-yr-old woman was semicomatose with bilaterally fixed dilated pupil, abducted eyes, and ptosis. A computed tomography demonstrated extensive hemorrhage spreading around the both Sylvian and interhemisheric fissure without focal mass effect. Intracranial pressure via extraventricular drainage before surgery was 15-50 mmHg. Three months later, brain MRI showed infarction of left posterior cerebral artery territory and lacuna infarction of the pons. Eleven months after aneurysm repair, nerve palsy improved slowly and recovered partially. The patient communicated well with simple words. The author reviewed and discussed the possible mechanism of this rare neuro-ophthalmological manifestation in view of a false localizing sign.

Optic Aphasia: A Case Study

Optic aphasia is a rare syndrome in which patients are unable to name visually presented objects but have no difficulty in naming those objects on tactile or verbal presentation. We report a 79-year-old man who exhibited anomic aphasia after a left posterior cerebral artery territory infarction. His naming ability was intact on tactile and verbal semantic presentation. The results of the systematic assessment of visual processing of objects and letters indicated that he had optic aphasia with mixed features of visual associative agnosia. Interestingly, although he had difficulty reading Hanja (an ideogram), he could point to Hanja letters on verbal description of their meaning, suggesting that the processes of recognizing objects and Hanja share a common mechanism.

Traumatic posterior cerebral artery occlusion in a 14-month-old child

Following a head injury, a 14-month-old male presented with neck stiffness and 24 hours later developed bilateral lateral rectus palsies. An unenhanced cerebral computed tomographic scan performed on admission revealed evidence of subarachnoid hemorrhage, cerebral edema, and mild-to-moderate compensated supratentorial hydrocephalus. A second scan performed 96 hours after the head injury revealed a mural thrombus at the tip of the basilar artery without any evidence of infarction. A third scan performed 12 days later revealed that the thrombus had resolved. However, a left posterior cerebral artery territory infarct was visualized. We postulate that the thrombus had embolized to the left posterior cerebral artery and caused occlusion of its cortical branch and subsequent infarction. A magnetic resonance angiography performed 20 days later excluded any vascular abnormality. The bilateral lateral rectus palsies persisted at the 6-month follow-up. To our knowledge, a head injury leading to a posterior cerebral artery territory infarct has not been reported earlier in a young child.

Posterior cerebral artery infarction associated with carotid dissection

Posterior circulation stroke may rarely be associated with occlusive disease in the anterior circulation, such as in the context of a direct (fetal) origin of the posterior cerebral artery (PCA) from the internal carotid artery (ICA), or in the presence of a persistent trigeminal artery. Carotid dissection is an increasingly recognized cause of anterior circulation ischemia. It is possible that in the setting of certain cerebral hemodynamics, embolism from carotid dissection could cause PCA infarction via a patent posterior communicating artery. We report the MR and MR angiography findings of cerebral dynamics whereby a patient presents with posterior circulation symptoms from anterior circulation pathology: left ICA dissection with subsequent left PCA territory infarction. Cerebral hemodynamics may allow PCA infarction from carotid disease even in the absence of a fetal PCA origin. This report also broadens the spectrum of stroke associated with carotid dissection.