Clinical presentation of posterior cerebral artery occlusions – Clinical rationale for a more aggressive therapeutic strategy?

Abstract

Introduction A proximal occlusion of the posterior cerebral artery (PCA) can affect patients severely and clinical outcome might be poor. Aim of this paper is to describe clinical presentation, diagnostic findings and outcome of patients suffering from ischemia in the PCA territory. Methods We conducted a retrospective analysis of clinically affected patients with imaging-based evidence of ischemia within in the PCA territory at a comprehensive stroke center over a six-year period. Clinical (including demographics, National Institutes of Health Stroke Scale, NIHSS, modified Rankin Sclae, mRS), imaging (including occlusion site and brain infarction) and therapeutic data were evaluated. A favorable outcome was defined as an mRS ≤2. Results Two hundred thirty-five patients were clinically affected with evidence of PCA ischemia detected by cross-sectional imaging. One-hundred fourty-five patients demonstrated an occlusion of the PCA including 43/145 (30%) with P1 occlusion, 80/145 (55%) with P2 and 22/145 (15%) with P3 occlusion. The most frequent symptom was hemi−/ quadrantanopsia (181/235, 77%). Sixty-eight patients (29%) suffered from hemiparesis. The occurrence of a hemiparesis was associated with a P1 occlusion (27/43, 63% vs. 41/192, 21%; p < 0.0001). Hemi−/quadrantanopsia was less frequently associated with a P1 occlusion (26/43, 61% vs. 155/192, 81%; p = 0.0043). P1 occlusions more frequently showed thalamic infarction (28/43, 65% vs. 65/192, 34%; p < 0.0001). At discharge, patients with P1 occlusion more often showed a poor outcome (mRS > 2, 30/43, 70% vs. 55/192, 29%; p < 0.0001). Conclusion Hemiparesis due to P1 occlusion is a common phenomenon in stroke patients and associated with a poor clinical outcome.

Endovascular Treatment of Acute Ischemic Stroke Due to Isolated Proximal Posterior Artery Occlusion

“…The perforating arteries from the P1 segment and junction of the P1‒P2 supply blood to the upper midbrain, thalamus, and hypothalamus. The territory of the P2 segment includes the lateral geniculate corpus and the visual radiation adjacent to the temporal lobe ( 4 ). Therefore, occlusion of the PPCA often leads to infarction of the midbrain, thalamus, temporal lobe, and occipital lobe.…”

“…The territory of the proximal posterior cerebral artery (PPCA) usually has poor collaterals with a number of nerve fibers. PPCA occlusion involving thalamic perforating arteries, such as the Percheron artery, with abnormal variants can lead to severe neuropsychological deficits, visual symptoms, and unconsciousness ( 4 , 5 ). However, no previous trials have focused on the effect of EVT on AIS due to PPCA occlusion ( 6 , 7 ).…”

Endovascular intervention for bilateral paramedian thalamic stroke due to occlusion of the unilateral P1 segment of the posterior cerebral artery: illustrative cases

“…However, if the basilar artery appears patent on CT angiography or magnetic resonance angiography, the diagnosis might be delayed and misinterpreted by physicians, especially nonneurologists; hence, only conservative management might be administered. 6 , 12 …”

Unilateral Oculomotor Nerve Palsy as a Rare Manifestation of Isolated Pre-Communicating Segment of Posterior Cerebral Artery Thrombosis

“…4,5 Unilateral CN III palsy is an atypical presentation of P1 segment thrombosis. 5 Usually, patients with P1 ischemic stroke present with hemiparesis, sensory loss, and visual problems, 6,7 as P1 perforating branches supply cerebral peduncles, tegmentum, and geniculate bodies, colliculi, and pulvinar of thalamus. 8 Blood supplies of the proximal part of the third cranial nerve could explain CN III palsy following an isolated P1 segment.…”