Acute ischemic stroke of the posterior cerebral artery (PCA) presents with variable symptoms that may initially make it challenging to diagnose. Common etiologies of PCA stroke include large and small artery disease, atherosclerosis, and cardioembolism. We present a 69-year-old male, initially diagnosed with sinusitis at an urgent care facility, who presented with worsening headache and peripheral vision loss following exposure to diesel vapor and exhaust. Physical examination revealed a right monocular temporal hemianopia and subsequent imaging showed infarction of the left occipital lobe. Due to the length of time between the onset of the infarct and medical treatment, angiography and physical intervention were not indicated and management was done medically. This case presents a unique exposure prior to the development of a PCA stroke, as well as an atypical visual defect and suggests that physicians should consider neuroimaging in patients with nonspecific neurological findings such as new-onset headache and vision changes.

The transcranial color-coded duplex sonography (TCCS) is a technique that enables a direct visualization of the basal cerebral arteries. The visualization is possible through Doppler sonography and the blood flow velocities of the arteries which are color-coded. On the opposite, TCD allows only to record the arterial blood flow velocities without direct visualization. The identification of the arteries is based on the depth of recording and flow direction. 2. A good knowledge of the anatomy of the intracranial and extracranial arteries is requested to evaluate them in an efficient way with TCCS. 3. The Circle of Willis is incomplete in 40-65% of the cases. 4. In total, 10-20% of patients do not have an accessible transtemporal acoustic window to insonate. 5. The insonation angle during the transcranial color-coded duplex sonography (TCCS) study is very important. It is mandatory to keep it as low as possible (<60°), for an optimal interpretation of the flow velocity in the cerebral arteries. 6. Transcranial color-coded duplex sonography (TCCS) is very useful to approach the brain perfusion, but many elements should be taken into consideration to analyze the results (anemia, fever, systemic blood pressure, angle of insonation, etc.) of cerebral hemodynamics in many clinical contexts of critical patients. But remember that we must contemplate that there are certain general limitations at the time of the C. N. Rodríguez (

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Physical examination of a critically ill patient with acute primary or secondary neurological injury is often insufficient for medical decision making. Transcranial Doppler/transcranial color coded sonography (TCD/TCCS) is a useful physiologic tool allowing one to individualize the management of each patient to optimize cerebral hemodynamics. 2. Pulsatility index (PI) is calculated by subtracting the peak systolic velocity (PSV) from the end diastolic flow velocity (EDV) and dividing the difference by the mean flow velocity (MVF); [PI = (PSV − EDV)/MVF]. 3. Pulsatility Index is dependent on multiple variables including cerebrovascular resistance (CVR). 4. Despite the correlative value of PI obtained from TCD/TCCS, the external ventricular drain remains the gold standard in the measurement of intracranial pressure (ICP).