Cerebral artery thrombosis as a cause of striatocapsular infarction. a histopathological case study

Striatocapsular infarction is a distinct form of stroke, but few histopathological studies have been performed concerning acute lesions. We report the postmortem findings of a patient with an infarct who died shortly after onset. A 72-year-old man died of acute myocardial infarction 6 days after the onset of left-sided striatocapsular infarction. Autopsy revealed thrombus formation of the left middle cerebral artery (MCA) trunk. The lateral striate arteries irrigating the area of the infarct branched off distal to the arterial segment occluded with a thrombus. The cortical vessels were perfused by leptomeningeal collaterals. This report histopathologically confirmed thrombus formation of the MCA resulting in striatocapsular infarction.     

大脑中动脉狭窄脑深部小梗死发病机制的研究

目的 研究大脑中动脉粥样硬化性狭窄患者脑深部小梗死的发生频率和发病机制。方法86例发病时间〈1周的急件脑梗死患者，行经颅多普勒超声、彩色超声、磁共振血管造影及功能磁共振成像等检查方法被明确诊断为症状性大脑中动脉粥样硬化性狭窄，并排除颈内动脉病变、心源性栓塞以及非动脉粥样硬化性狭窄。利用磁共振扩散加权成像观察梗死灶的形态学表现及特点，分析其发病机制。结果37例（43．02％）症状性大脑中动脉粥样硬化性狭窄患者存在深部小梗死，多呈孤立性单发病灶。其中内囊纹状体梗死及巨大腔隙者18例（20．93％），梗死灶体积多超过两个层面，少数病灶呈多灶分布的特点；直径较小的腔隙性梗死19例（22．09％），梗死灶体积〈15mm，多位于一个层面内。伴有大脑中动脉粥样硬化性狭窄的深部小梗死的患者，病情多不稳定，预后较差。所有脑深部小梗死患者均伴有大脑中动脉主干支狭窄，且梗死灶体积与大脑中动脉粥样硬化性狭窄程度有关，内囊纹状体梗死多见于大脑中动脉重度狭窄者。结论约50％大脑中动脉粥样硬化性狭窄患者存在脑深部小梗死，其发病机制与大脑中动脉粥样硬化斑块或斑块残端血栓蔓延堵塞深穿支动脉入口有关。对此类患者的治疗不同于经典的腔隙性脑梗死。     

纹状体内囊区域内不同面积梗死的病因机制的探讨

目的通过对纹状体内囊区域大小不同面积梗死患者的临床表现与磁共振(MRI)影像特点的对比性分析,探究其发病的病因和机制。方法分析根据发病48h内磁共振弥散加权像(DWI)的结果,确定梗死的部位及大小,按照纹状体内囊梗死(SCI)的影像诊断标准,将58例患者分为(SCI组)26例和(非SCI组)32例。并分别进行临床表现与影像特点的分组对比。结果临床资料显示,两组在NIHSS评分、血压、血糖及CRP等动脉粥样硬化危险因素指标均有显著差异。影像资料显示,病灶分布情况、白质病变在2组对比差异有统计学意义,颈内动脉颅内段、大脑中动脉受累无显著差异。结论 (SCI组)动脉源性或心源性栓塞是主要病因之一,(非SCI组)病因考虑动脉粥样硬化血栓形成。     

The Role of Transcranial Doppler in Symptomatic Striatocapsular Small Deep Infarction

BACKGROUND AND PURPOSE: The transcranial Doppler (TCD) findings in symptomatic small deep infarction are not well known. The aim of this study was to evaluate the role of TCD in striatocapsular small deep infarctions (SSDIs). METHODS: The cerebral angiography and TCD findings were analyzed on 100 patients with symptomatic cerebral infarcts on the middle cerebral artery (MCA) territory. The sensitivity, specificity, and accuracy of TCD in detecting the MCA lesions were compared between lacunar group (the patients with lacunar syndrome and SSDIs on magnetic resonance image) and nonlacunar group. RESULTS: Thirty-eight patients were classified as the lacunar group, whereas 62 patients as the nonlacunar group. On angiography, occlusive lesion of MCA was found in 18 of the lacunar group and 24 patients of the nonlacunar group. The degree of MCA stenosis was higher in the nonlacunar group (80.8% +/- 21.2%) than the lacunar group (60.4% +/- 21.6%). The accuracy of TCD for the detection of MCA stenosis was not different between the groups. However, the sensitivity of TCD in the lacunar group was lower (72%) than in the nonlacunar group (88%), and it might have been due to the difference in the degree of MCA stenosis among the groups. CONCLUSION: Occlusive lesions of the MCA should be considered as a potential cause of SSDIs. In this respect, TCD may be used for screening candidates for conventional angiography in those patients. High rate of mild-degree stenosis of MCA in patients with SSDIs, however, caused a risk for missing such stenosis on TCD.     

116例大脑中动脉病变患者脑梗死类型分布和脑灌注异常分析

目的 应用神经影像检查,分析大脑中动脉闭塞性疾病(MCAOD)患者梗死类型分布和脑灌注异常. 方法 对经CT血管造影(CTA)证实的116例MCAOD患者的CT平扫、CT灌注成像(CTP)和CTA的影像资料进行回顾性分析,确定其脑梗死类型分布和脑灌注改变. 结果 116例患者中,CTA共检出133条大脑中动脉(MCA)狭窄或闭塞,其中单侧者99例,双侧者17例.其中MCA闭塞25条,重度狭窄39条,中、轻度狭窄69条.CT或MRI显示腔隙性脑梗死(LIS)45例,各型分水岭脑梗死(CWSI)38例,流域性脑梗死26例,纹状体内囊梗死(SCI)10例,未检出梗死病灶14例.CTP显示MCA供血区内脑血流灌注异常96例,其中58例有MCA供血区的大范围血流灌注减低.未检出血流灌注异常者37例. 结论 由于MCA狭窄的部位、程度和发病机制的不同以及侧支循环的建立,MCAOD可造成不同类型的脑梗死和血流灌注异常.     

Cardioembolic infarction in the Sagrat Cor-Alianza Hospital of Barcelona Stroke Registry

Objectives - To describe the clinical features of cardioembolic infarcts. Material & methods - Cardioembolic infarct was diagnosed in 231 (15.4%) of 1500 consecutive stroke patients included in a prospective stroke registry over an 8-year period. Results - Cardiac sources of emboli included isolated atrial dysrhythmia (57.1%), valvular heart disease (20.3%), and coronary artery disease (18.2%). Patients with cardioembolic stroke showed a significantly higher ( P < 0.00001) frequency of sudden onset of neurological deficit (79.7%) and altered consciousness (31.2%) than patients with lacunar infarct (38% and 1.9%) and atherothrombotic infarction (46% and 24%). Eleven patients had a spectacular shrinking deficit and 6 a presumed cardioembolic lacunar infarct. Early recurrent embolisms occurred in 6.5% of patients mostly (60%) within 7 days of initial embolism. In-hospital mortality was 27.3% (0.8% in lacunar infarcts, 21.7% in atherothrombotic infarction, P < 0.00001). Conclusion - Cardioembolic infarction is a severe subtype of stroke with a high risk of early death. Clinical features at stroke onset may help clinicians to differentiate cerebral infarction subtypes and to establish prognosis more accurately.     

Distinct clinical expressions of striatocapsular infarction according to cortical manifestations

Striatocapsular infarction is known to have various neurologic manifestations including cortical symptoms. However, striatocapsular infarction patients without cortical dysfunctions can be easily found. Therefore, we tried to evaluate the properties and pathogenesis of two distinct expressions of striatocapsular infarction, striatocapsular infarction with and without cortical dysfunctions respectively. Forty-eight patients were divided into two groups according to their initial manifestations. Forty-eight patients with striatocapsular infarction were divided into cortical type of striatocapsular infarction (CSCI) and non-cortical type (NCSCI) according to their initial manifestations. We compared the properties such as stroke risk factors, laboratory data, and clinical features and assessed magnetic resonance imaging (MRI) and MR angiography for possible mechanisms in each type of striatocapsular infarction. Patients with CSCI and those with NCSCI had similar characteristics, laboratory data and morphologic findings in MRI. CSCI patients had more profound initial neurologic manifestations [Both National Institutes of Health Stroke Scale (NIHSS) score and Barthel index]. In MR angiography, patients with CSCI showed more frequent single middle cerebral artery (MCA) stenosis, whereas NCSCI patients had findings that were more heterogeneous. In conclusion, we found that not all the patients with striatocapsular infarction had cortical dysfunctions. It is possible for lesions with similar size and location to have different manifestations (cortical or non-cortical) according to their vascular integrity.     

大脑中动脉狭窄与其深穿支供血区单发脑梗死的关系

目的 分析大脑中动脉(MCA)深穿支供血区单发脑梗死的形态学表现,进一步探讨其与MCA狭窄的关系.方法 连续入选2005年1月至2006年12月于北京协和医院神经科住院治疗急性脑梗死,并经头颅DWI检查明确急性梗死灶为单发,且位于MCA深穿支供血区域的55例患者;所有患者均行TCD和MRA检查,颅外颈内动脉狭窄>50%以及有可疑心源性栓子来源的患者从研究中排除.根据是否存在病灶同侧MCA狭窄将入选患者分为两组:MCA狭窄组(14例)与MCA正常组(41例).测量DWI上急性梗死灶的直径、面积和体积,并将直径≤2 cm归为经典腔隙性梗死,直径>2 cm归为纹状体内囊梗死.DWI上的梗死灶区分为基底节区、侧脑室体旁和同时累及上述2个部位,并判断MRI T2>像上皮质下多发陈旧性小梗死灶或白质疏松是否存在.结果 55例患者中,病灶侧MCA狭窄患者14例(25.5%),MCA正常患者41例(74.5%).MCA狭窄组中经典腔隙性梗死占71.4%,MCA正常组中经典腔隙性梗死占67.3%,差异无统计学意义(χ2=0.147,P=0.701).MCA狭窄组与正常组患者MCA深穿支梗死病灶的大小(包括直径、面积及体积)差异均无统计学意义.MCA正常组和MCA狭窄组病灶在基底节区、侧脑室体旁及基底节区+侧脑室体旁分布的比例依次为:正常组31.7%、17.1%和51.2%;狭窄组35.7%、28.6%和35.7%,两组间差异无统计学意义(χ2=1.272,P=0.529).同时存在皮质下多发陈旧性小梗死灶或白质疏松的患者在MCA正常组有23例(56.1%),在MCA狭窄组有3例(21.4%),二者差异有统计学意义(χ2=5.033,P=0.025).结论 MCA深穿支供血区梗死具有不同的发病机制,MCA狭窄和穿支动脉本身病变均可造成深穿支供血区单发脑梗死.梗死灶的大小、体积及梗死发生的部位与是否存在同侧大脑中动脉狭窄无明显相关性,而同时存在皮质下多发陈旧性小梗死灶或白质疏松对穿支动脉病变有提示作用.     

Middle cerebral artery stenosis is a major clinical determinant in striatocapsular small, deep infarction

BACKGROUND: The significance of the stenotic lesions of the middle cerebral artery (MCA) in Asian patients with striatocapsular small, deep infarctions (SSDIs) remains undetermined. OBJECTIVES: To investigate the frequency of stenotic lesions of the MCA in patients with SSDIs and to evaluate clinical and radiological features in those same patients. SETTING: Acute stroke registry of a university hospital. PATIENTS AND METHODS: One hundred two Korean patients with acute symptomatic SSDIs underwent cerebral angiography or magnetic resonance angiography and echocardiography. We divided these patients into 2 groups-patients with and without MCA occlusive lesions. The clinical and magnetic resonance image features were compared between these 2 groups. RESULTS: Thirty-seven patients (36%) had an ipsilateral proximal MCA lesion, whereas 65 patients (64%) showed no MCA abnormality on cerebral angiography or magnetic resonance angiography. Among 65 patients without an MCA lesion, 18 had an embolic source; the remaining 37 patients had no demonstrable embolic source. There were significant differences in the temporal profile and magnetic resonance imaging findings between the groups. Although the type of lacunar syndrome and the volume of infarcts did not differ between the groups, the unstable temporal profile and magnetic resonance imaging findings of multiple small infarcts in the symptomatic hemisphere were frequently observed in patients with MCA lesions. CONCLUSIONS: The proximal MCA lesion was a common cause of SSDIs in Korean patients. Depending on the existence of an MCA lesion, the clinical course and magnetic resonance imaging feature of the patients with SSDIs were different.     

Differential diagnosis of acute ischemic stroke and management on the basis of acute ischemic stroke subtype]

Recent advances in neuro-imaging technology assist early clinical diagnosis for ischemic stroke subtype. The precise early diagnosis for stroke subtype plays an important role for the management in patients with acute cerebral infarction. The differential diagnosis is made according to the algorithm in the modified the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, with reference to the results of diffusion-weighted MRI and MRA. Artery-to-artery embolism and branch atheromatus disease are diagnosed as atherothrombotic infarction according to this algorithm. Thrombolytic therapy is recommended in cardioembolic stroke within 3 hours after onset. The anticoagulant therapy with heparin is often used to prevent the recurrence for thrombosis in acute cardioemboic infarction. The selective thrombin inhibitor has recently been used in the treatment of acute atherothrombotic infarction. The antiplatelet therapy with aspirin is recommended in acute atherothrombotic infarction and lacunar infarction. The sodium ozagrel is recommended in the treatment of acute lacunar infarction. The treatment of acute ischemic stroke should be managed according to Japanese Guidelines for the management of stroke (2004).     

Blood flow velocities of cerebral arteries in lacunar infarction and other ischemic strokes

Blood flow velocity is an important determinant of vascular hemodynamics. The aim of the present study was to determine the mean flow velocities (MFVs) of cerebral arteries in patients with ischemic stroke, comparing lacunar and nonlacunar infarctions. 388 consecutive patients were examined for lacunar infarction, other subtypes of ischemic stroke, and the presence of underlying internal carotid artery steno-occlusion (ICS). MFVs were measured using transcranial Doppler along the full segments of each cerebral artery including both right and left middle cerebral arteries, basilar artery, and both of the vertebral arteries. The patients were categorized into two major groups: lacunar infarction, and nonlacunar infarction with or without underlying ICS. The characteristics of patients with lacunar infarction (n=83, 21.4%) were significantly different from those with nonlacunar infarctions: younger age, lower prevalence of type 2 diabetes, and lower concentration of plasma total homocysteine. The patients with lacunar infarction had lower MFVs in cerebral arteries than the patients with nonlacunar infarctions, especially in the posterior circulation vessels such as the basilar artery and both vertebral arteries. Different hemodynamics might be pathophysiologically associated with the lacunar infarction, compared with the other subtypes of ischemic stroke.     

缺血性脑卒中亚型及其危险因素与脑白质变性的关系

目的探讨缺血性脑卒中亚型及其危险因素与脑白质变性(LA)的关系。方法对213例伴LA的缺血性脑卒中患者的LA程度进行分级(LA1、LA2、LA3),分析其与缺血性脑卒中亚型(短暂脑缺血发作、腔隙性脑梗死、动脉血栓形成和心源性脑梗死)及其危险因素(年龄、性别、高血压、糖尿病及冠心病等)的关系。结果213例伴LA的缺血性脑卒中患者中,LA2和LA3患者的年龄明显高于LA1患者(均P<0.05);腔隙性脑梗死患者LA3的发生率明显高于其他缺血性脑卒中亚型(均P<0.05);与LA程度明显相关的因素为年龄(OR 0.69,95%CI:0.49~0.97)和腔隙性脑梗死(OR 0.01,95%CI:0.00~0.33)(均P<0.05)。结论与LA相关的危险因素是高龄和腔隙性脑梗死;可能的机制为穿支动脉硬化和血压调节障碍影响脑白质血流供应,引起白质局部坏死、腔隙形成或弥漫性LA。     

Polymorphisms at the LDLR locus may be associated with ischemic cerebrovascular disease independent of lipid profile

The low-density lipoprotein receptor (LDLR) gene has been reported to be associated with cerebral infarction. This study aimed to explore 2 genetic LDLR variants, rs688 and rs5925, for their potential roles in cerebral infarction. This genetic association study was conducted within an isolated Taiwanese population; 815 ischemic stroke patients (431 with atherothrombotic stroke and 384 with lacunar infarction) and 430 normal controls were enrolled. There was no significant difference in the genetic frequency of rs688 and rs5925 between the control group and overall ischemic stroke, atherothrombotic stroke, or lacunar infarct groups. However, when analyzing the association between the haplotypes related to rs688 and rs5925 and cerebral ischemic stroke, the most common haplotype allele CT was used as the reference allele, and the haplotype TC associated with a 65% increased risk of overall ischemic stroke, 72% increased risk of atherothrombotic stroke, and 70% increased risk of lacunar infarction; this indicated a synergistic effect between these 2 single-nucleotide polymorphisms. The LDLR analysis based on the haplotypes rs688 and rs5925 was conducted in a Taiwanese population and provided preliminary evidence suggesting that genetic polymorphisms of LDLR are associated with cerebral infarction.     

Color-coded Ultrasound Diagnosis of Vascular Occlusion in Acute Ischemic Stroke

A combination of extracranial and transcranial color-coded sonography was used to identify the patterns of vascular occlusion in 47 patients with acute ischemic stroke. Total anterior circulation infarction (n = 20) was associated with internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion (n = 8 and 9, respectively), or with significant reduction in ipsilateral MCA velocities (n = 5) Patients with partial anterior circulation (n = 22) infarction had patency of the ipsilateral ICA and MCA. In this group, significant reduction of ipsilateral MCA velocities (n = 7) was associated with more extensive infarcts on conventional neuroimaging (n = 6), suggesting multiple MCA branch occlusions. Ultrasound imagmg was unable to identify underlying vascular pathology in patients with postenor circulation infarction or with lacunar infarction (n = 5). An ultrasound-based approach enables noninvasive identification of major vascular pathology of the anterior cerebral circulation in patients with acute cerebral infarction. It may be useful for the rapid identification of patients most and those least likely to benefit from acute intervention, and for monitoring their response.     

Middle cerebral artery occlusive disease: The New England medical center stroke registry.

To analyze the clinical features, vascular lesions, and infarct distribution in Asian and white patients with middle cerebral artery (MCA) territory ischemia, we studied age, sex, race, risk factors, angiographic, and neuroimaging findings among patients in the New England Medical Center Stroke Registry. We included patients with well-defined intrinsic occlusive lesions of the MCAs and patients with embolic MCA territory infarcts. Among 695 patients in the stroke registry, 89 (12.8%) qualified. They had 28 MCA intrinsic stenoses, 17 MCA embolic occlusions (cardiogenic or unknown origin), and 44 carotid artery (CA) stenoses or occlusions. MCA intrinsic disease patients were more often Asians and women, and more often had hypertension. Asians were older than whites. Coronary artery disease (27%), peripheral vascular disease (20.5%), and smoking (39%) were more common in CA disease patients. The most common site of MCA intrinsic stenosis (78%) and embolic occlusion (59%) was the mainstem MCA. Infarcts in patients with MCA intrinsic disease mostly involved the striatocapsular area (61%). Infarcts in patients with MCA embolic occlusion (75%) and CA disease (43%) most often involved the parietal lobe. In our hospital, most patients with MCA intrinsic disease are Asians and women and have hypertension and striatocapsular infarctions. Asian patients are usually older than white patients. The most common site of vascular lesions is the mainstem MCA.     

动脉粥样硬化性大脑中动脉区域TIA功能磁共振成像分析

目的利用弥散加权成像(DWI)、磁共振血管成像(MRA)对大脑中动脉(MCA)区域TIA进行解剖性定位,评价磁共振对临床实践的指导意义。方法对32例TIA患者,在发作1.5h~7d内行头部MRI、DWI、MRA检查,对DWI图像上的高信号与T2WI像、MRA、临床症状、体征进行对照研究。结果2例DWI正常,但MRA颅内大脑中动脉闭塞,病变血管与临床症状相一致。12例DWI正常,MRA仅轻度狭窄或正常。3例DWI有高信号,T2WI无相应病灶为超早期脑梗死,其中MRA1例动脉硬化样改变,2例大脑中动脉闭塞,病灶与体征相符。15例DWI有高信号、T2WI有相应病灶,2例为早期脑梗死、13例为腔隙性脑梗死,其中MRA8例颅内大血管轻到中度狭窄,2例严重狭窄。MRI显示20例(62.5%)存在多发陈旧腔隙性梗死灶。对于TIA患者发作时MRA相应病变进行χ2四格表精确检验,DWI异常组与正常组比较P<0.05,MRA大血管病变是TIA预后形成梗死的独立危险因素。结论对TIA患者行MRI、DWI、MRA检查,能及时发现超早期脑梗死,还能对新发腔隙性脑梗死准确定位,科学指导临床早期干预治疗。MRA可提供1.2级大血管的供血状态,指导后续的2级预防。     

脑穿支动脉病变梗死类型和神经影像学研究进展

大脑前动脉、大脑中动脉及后循环血管的穿支动脉,如豆纹动脉、脉络膜前动脉（anterior choroidal artery,AChA）和髓质动脉等,阻塞会导致脑深部缺血性病变。不同穿支动脉梗死类型不 同：豆纹动脉供血区域的梗死类型为腔隙性梗死、穿支动脉粥样硬化病型梗死和纹状体内囊梗死; AChA病变可导致AChA综合征;髓质分支梗死会导致半卵圆中心、放射冠部位的边界区梗死。7T二维 相位对比MRI、三维时间飞跃法MRA和三维快速自旋回波T1WI序列等神经影像学新技术有助于确定穿 支动脉早期病变,并可早期发现疾病的发生发展。     

动脉硬化性大脑中动脉狭窄或闭塞所致脑梗死类型

目的探讨动脉硬化性大脑中动脉狭窄或闭塞性疾病(MCAOD)所致脑梗死的类型。方法对50例经颅脑MRA或DSA确诊的症状性MCAOD患者进行研究,依据其头部弥散加权成像(DWI)和T2W的改变对脑梗死分型。结果50例患者共发现57条动脉硬化性大脑中动脉狭窄或闭塞,未发现病灶的有6(占12．0%)个大脑半球,多发性脑梗死和单发脑梗死分别见于13(占22．8%)个和38(占66．7%)个大脑半球。脑分水岭梗死、流域性脑梗死、半卵圆区脑梗死、多发性散在点状脑梗死(MSSI)、腔隙性脑梗死分别见于18(占31．6%)个、12(占21．1%)个、6(占10．5%)个、2(占3．5%)个和1(占1．8%)个大脑半球。结论MCAOD可引起各种类型的脑梗死,脑分水岭梗死约占1/3,动脉粥样硬化性血栓形成约占1/5,纹状体内囊梗死约占1/5,主要发病机制与动脉-动脉栓塞和低灌注有关。     

Differences between hypertensive and non-hypertensive ischemic stroke

We compared risk factors, clinical features, neuroimaging data, and outcome between hypertensive and non-hypertensive ischemic stroke patients. Differential features of ischemic stroke patients with hypertension (n = 768) and without hypertension (n = 705) were assessed by bivariate analysis. Independent predictors of hypertensive ischemic stroke were determined by multivariate analysis. Atherothrombotic infarction and lacunar infarct were significantly more common in the hypertensive group, in which older age and a higher occurrence of previous cerebral infarction, hyperlipidemia, acute stroke onset, lacunar syndrome, and pons topography was also observed. Age of 85 years or older, valvular heart disease, and decreased consciousness were more common in non-hypertensive patients. After multivariate analysis, lacunar syndrome, female gender, and previous infarction were directly associated with hypertensive ischemic stroke. Age of 85 years or older and valvular heart disease were inversely associated with hypertensive ischemic stroke. Hypertension was the main cardiovascular risk factor only for lacunes and atherothrombotic infarction, that is, ischemic stroke associated with small- and large-artery disease.     

Posterior cerebral artery infarction from middle cerebral artery infarction

BACKGROUND: While it is known that posterior cerebral artery (PCA) infarction may simulate middle cerebral artery (MCA) infarction, the frequency and localization of this occurrence are unknown. OBJECTIVE: To determine the frequency of PCA infarction mimicking MCA infarction and the territory of the PCA most commonly involved in this simulation. DESIGN: We studied 202 patients with isolated infarction in the PCA admitted to our stroke center to determine the frequency of PCA infarction simulating MCA infarction, the involved PCA territory, and the patterns of clinical presentation. RESULTS: We found 36 patients (17.8%) with PCA ischemic stroke who had clinical features suggesting MCA stroke. The PCA territory most commonly involved was the superficial PCA territory (66.7%), followed by the proximal PCA territory (16.7%) and both the proximal and the superficial PCA territories (16.7%). The principal stroke mechanism was cardioembolic (54.1%) in the superficial PCA territory, lacunar (46.2%) in the proximal PCA territory, and undetermined (40.2%) in both the proximal and the superficial territories. Among the 36 patients, the most common clinical associations were aphasia (13 patients), visuospatial neglect (13 patients), and severe hemiparesis (7 patients). CONCLUSIONS: Posterior cerebral artery infarction simulating MCA infarction is more common than previously thought. Early recognition of the different stroke subtypes in these 2 arteries may allow specific management.