Kristen Hudson, MD Valerie Biousse , MD
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Transcript of Kristen Hudson, MD Valerie Biousse , MD
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Posterior Cerebral Artery Infarction from Vertebral Artery Dissection,
Presenting with Homonymous Hemianopia
Kristen Hudson, MD Valerie Biousse, MD
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Abbreviations
• PCA: Posterior cerebral artery • ICA: Internal carotid artery • VA: Vertebral artery • MCA: Middle cerebral artery • ACA: Anterior cerebral artery • R: Right • L: Left • MRA: Magnetic resonance angiography
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Clinical Presentation
• History – 49 y/o healthy man – Acute onset left upper and lower extremity
weakness and incoordination resulting in ground level fall
– Associated with dull headache
• Neurologic exam: – Left homonymous hemianopia – Left hemisensory (face, arm, and leg) loss – Mild left hemiparesis
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Humphrey Visual Fields (HVF)
LEFT EYE RIGHT EYE
Complete Left Homonymous Hemianopia
Figure 1a Figure 1b
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Brain MRI (8 hours after symptom onset) Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC)
DWI ADC
Note hyperintense (bright) areas on DWI (red arrows) with corresponding dark on ADC (green arrows) indicating acute infarction in right PCA territory (occipital and inferior temporal lobes)
Figure 2a Figure 2b
Axial images, progressing inferior to superior – 1 of 4
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Brain MRI (8 hours after symptom onset) Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC)
DWI ADC
Figure 3a Figure 3b
Axial images, progressing inferior to superior – 2 of 4
Note bright on DWI (red arrows) and corresponding dark on ADC (green arrows) indicating acute infarction in right PCA territory (occipital and inferior temporal lobes)
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Brain MRI (8 hours after symptom onset) Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC)
DWI ADC
Figure 4a Figure 4b
Axial images, progressing inferior to superior – 3 of 4
Note bright on DWI (red arrows) and corresponding dark on ADC (green arrows) indicating acute infarction in right occipital lobe and thalamus
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Brain MRI (8 hours after symptom onset) Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC)
DWI ADC
Figure 5a Figure 5b
Axial images, progressing inferior to superior – 4 of 4
Note bright on DWI (red arrows) and corresponding dark on ADC (green arrows) indicating acute infarction in right occipital lobe and thalamus
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MRA Head with contrast– Source Images Axial images, progressing inferior to superior – 1 of 2
Figure 6a
Figure 6b
Figure 6c
Lack of flow-related signal in left VA (green circle), with minimal signal visualized in only most proximal VA (green arrows) near vertebrobasilar junction. Normal flow-related signal in bilateral ICAs and right VA (red arrows).
R ICA
R ICA
L ICA
R ICA L ICA
L ICA
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Axial images, progressing inferior to superior – 2 of 2
Note right PCA (red arrows) visualized to takeoff from basilar artery (yellow arrow) with initial flow-related signal, followed by loss of signal (red circle). Left PCA visualized on all slices for comparison (blue arrows).
Basilar Artery
Figure 7a
Figure 7b
Figure 7c
MRA Head with contrast– Source Images
R PCA
R PCA
L PCA
L PCA L PCA
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Note lack of visualization of the left VA (green arrows) and right PCA (red arrow) compared to normal (dominant) right VA and left PCA (blue arrow).
ACAs
R MCA L MCA
ACAs
R MCA L MCA
R VA
Basilar A
L PCA
R ICA
L ICA
L ICA
R ICA
Figure 8a Figure 8b
R VA
MRA Head with contrast– 3D reconstructions
Rotation: view from above Rotation: view from the back
L VA
R PCA
L VA
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Head CT without contrast (2.5 weeks later) Axial images, progressing inferior to superior
Hypodensity (red arrows) in right occipital and inferior temporal lobes corresponding to old infarction (2.5 weeks)
Figure 9b
Figure 9a
Figure 9d
Figure 9c
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Summary
• Right posterior cerebral artery ischemic infarction due to post traumatic (martial arts) left vertebral artery dissection with resulting right PCA occlusion. Left homonymous hemianopia due to right occipital lobe infarction
• Left hemisensory loss due to right thalamic infarction