Occipital infarction with hemianopsia from carotid occlusive disease

Extracranial internal carotid artery occlusive disease usually produces stroke in the middle cerebral artery territory or the border zone between the middle and anterior cerebral arteries. It is unusual for occipital infarction in the posterior cerebral artery territory to be caused by internal carotid artery disease despite the fact that the posterior cerebral artery may arise directly from the internal carotid artery as an anatomic variation. We describe a patient with a fetal posterior cerebral artery originating from the internal carotid artery, and the initial manifestation of his extracranial internal carotid artery occlusive disease was hemianopsia from occipital infarction.     

Thalamic infarcts: clinical syndromes, etiology, and prognosis

We studied forty patients with CT-proven thalamic infarcts without involvement of the superficial territory of the posterior cerebral artery. The delineation into four arterial thalamic territories (inferolateral, tuberothalamic, posterior choroidal, paramedian) corresponded clinically to four different syndromes. The most common etiologies were lacunar infarction, large artery atherosclerosis with presumed artery-to-artery embolism, cardioembolism, and migrainous stroke. We found no risk factor other than age or oral contraceptive use in six patients. One patient died in the acute phase. During follow-up (45.6 months), the stroke or death rate was 7.4% per year. Delayed pain developed in three patients and abnormal movements in three. Late disability was mainly secondary to persisting neuropsychological dysfunction (thalamic dementia).     

后循环缺血性卒中与认知障碍相关性研究

目的 探究后循环缺血性卒中与认知障碍发生的关系。 方法 连续选取2013年11月至2014年11月浙江大学医学院附属第一医院及嘉兴市第二医院收治的急 性后循环缺血性卒中患者67例,收集患者人口学、影像学及认知功能评价资料,并通过磁共振成像 统计梗死部位;通过简明精神状态量表、阿尔兹海默病评定量表认知分量表、临床痴呆量表评估认 知功能;根据认知诊断标准同时结合认知功能评价结果,将患者分为认知功能正常组、血管性轻度 认知障碍组、血管性痴呆组。 结果 67例患者中,认知功能正常32例（47.8%）、血管性轻度认知障碍20例（29.9%）,血 管性痴呆15例（2 2.4%）。通过校正年龄、性别、汉密尔顿抑郁评分等因素后,多因素回归分 析显示：颞枕叶缺血性卒中［比值比（odd ratio,OR）75.89,95%可信区间（confidence interval, C I ）3.92～1 470.06）］增加认知障碍发生风险,脑桥缺血性卒中患者发生认知障碍的风险比 非脑桥缺血性卒中降低90%（OR 0.10,95%CI 0.02～0.60）;进一步分析显示,颞枕叶缺血性卒 中（OR 542.24,95%CI 7.85～37 481.44）增加轻度认知障碍发生风险;小脑缺血性卒中（OR 12.49, 95%CI 1.03～151.58）增加血管性痴呆发生风险。 结论 50%以上后循环缺血性卒中患者发生认知障碍;其中颞枕叶及小脑缺血性卒中增加认知障碍 发生风险,脑桥缺血性卒中与认知障碍发生无显著相关性。     

Ruptured pediatric posterior cerebral artery aneurysm 9 years after the onset of Kawasaki disease: a case report

CASE REPORT: A 12-year-old boy who had a history of Kawasaki disease 9 years ago experienced a subarachnoid hemorrhage by ruptured right posterior cerebral artery aneurysm. On day 1 operation, as the aneurysm was very fragile and bled easily, two intraoperative ruptures, including a very premature rupture, were encountered. As a result, a left hemiparesis especially severe in the left hand was caused by the right anterior thalamic infarction due to the occlusion of a thalamo-perforating artery arising near the neck of the aneurysm. DISCUSSION: The histopathological examination of the intraoperative excised aneurysmal dome disclosed the thickening of the endothelial inner due to the endothelial hypertrophy and the invasion of inflammatory cells. This finding of the aneurysm was partially mimicking the finding of the coronary artery of the patients with Kawasaki disease. The combination of cerebral aneurysm and Kawasaki disease has never been reported until now, and the etiology of the aneurysm of this patient is unclear.     

Lateral thalamic infarcts

A patient with occlusion of the proximal posterior cerebral artery (PCA), a lateral thalamic infarct, and hemisensory loss later developed hemianopia and hemiparesis and had extensive PCA territory infarction in the midbrain, the lateral portion of the thalamus, and the occipital lobe noted at necropsy. Two other patients had lateral thalamic infarcts on computed tomography, normal angiographic findings, and presumed thalamogeniculate artery branch occlusion. There are three clinical syndromes associated with lateral thalamic infarction: (1) hemisensory loss, hemiataxia, and involuntary movements; (2) pure sensory stroke; and (3) sensory-motor stroke. Ataxia, adventitious movements, and sensory loss are due to infarction of the lateral, posterolateral, and posteromedial ventral nuclei caused by occlusion of the PCA proximal to the thalamogeniculate artery branches or by occlusion of large thalamogeniculate arteries. Pure sensory and sensory-motor strokes are due to smaller infarcts in the posterolateral-posteromedial ventral complex and adjacent internal capsule caused by occlusion of penetrating artery branches of the thalamogeniculate arteries.     

Unilateral Contrast Neurotoxicity as a Stroke Mimic After Cerebral Angiogram

Contrast neurotoxicity (CN) following exposure to iodinated contrast is uncommon, and usually presents as cortical blindness due to bilateral occipital lobe involvement. Unilateral cortical dysfunction due to CN could mimic an acute stroke and has been rarely described. We report the case of an 89‐year‐old female who developed a transient dense/complete left homonymous‐hemianopsia and left‐sided tactile extinction after undergoing a right internal carotid (ICA) artery rotational angiogram with a standard high‐volume iodinated contrast injection for 3D visualization a 6×4‐mm right posterior communicating artery aneurysm with a fetal posterior cerebral artery (PCA) incorporated in the neck. This was associated with transient fullness and loss of gray‐white matter differentiation in the right occipital and parietal lobes. The potential mechanism of CN in our case was the injection of a high volume of contrast in the ICA for the rotational angiogram. The presence of a right fetal PCA possibly allowed the contrast to reach the right occipital lobe. CN manifesting as an acute focal neurologic syndrome should be considered in the setting of recent iodinated contrast exposure.     

Delayed intravenous thrombolysis based on MRI mismatch in posterior circulation stroke

The current time-based approach for patient selection for intravenous (IV) thrombolysis in an acute stroke setting neglects the individual variation of cerebral blood flow impairment. This approach restricts the eligible patient population. In the last decade, advanced imaging and especially MRI diffusion- and perfusion-weighted imaging (DWI–PWI) techniques have been used to select patients for IV thrombolysis outside the current 4.5 h time window. Most of these studies focus on the anterior (carotid artery) cerebral circulation only. We report the case of an acute ischemic stroke due to a dissection of the right vertebral artery and occlusion of the posterior inferior cerebellar artery with good clinical outcome. The patient received IV thrombolysis far beyond the current established time window. This decision was based upon a marked MRI DWI–PWI mismatch zone in the posterior circulation territory.     

Proximal posterior cerebral artery occlusion simulating middle cerebral artery occlusion

We describe 12 cases of acute stroke in which clinical features of proximal posterior cerebral artery occlusion simulated the clinical syndrome of middle cerebral artery occlusion. The majority of patients developed contralateral hemiparesis, homonymous hemianopia, hemispatial neglect, and sensory loss or sensory inattention. All 8 patients with dominant hemisphere lesions were aphasic. Accurate diagnosis in each case was achieved only after a head CT, showing occipital lobe, thalamic, and inferomesial temporal lobe infarction. "Cortical" signs are probably explained by thalamic involvement. Recognition of this syndrome has implications for management and prognosis.     

Pure thalamic infarctions: Clinical findings

Our purpose in this study was to evaluate and review the risk factors, clinical profiles, and neuropsychologic abnormalities in patients with pure thalamic infarctions and to describe the clinical syndromes according to the thalamic arterial territory involved. We studied all patients with acute thalamic stroke admitted to our stroke unit over a 5-year period. We performed magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) on all patients. We classified patients into 4 thalamic artery territory subgroups based on MRI findings: thalamogeniculate, paramedian, polar, and posterior choroidal. Patients with pure thalamic infarction represented 2.4% of patients with ischemic stroke in our registry. There were 59 patients (39 men and 20 women; mean age, 62 ± 13 years) with thalamic infarctions that were confirmed by MRI. The main cause of thalamic infarction was small artery disease (75%). Hypertension (68%), hypercholesterolemia (29%), and diabetes mellitus (27%) were the most frequent risk factors. Hemisensory loss with or without motor and neuropsychologic deficit is highly associated with thalamogeniculate infarction, the most frequent type of thalamic stroke (51%). Paramedian infarction was the second most common type of thalamic infarction (34%) and is characterized by several neuropsychologic, oculomotor, and consciousness disturbances. Frontal-like syndrome with sensory motor findings is common in polar artery territory infarction (10%). Visual field defect is associated mainly with infarctions in the territory of the posterior choroidal artery (5%), probably caused by involvement of the lateral geniculate body. Approximately two thirds of the patients returned to their previous normal life. Cognitive deficits in patients with bilateral paramedian infarction persisted during the follow-up period, contrary to the other thalamic stroke subtypes. No patient died during follow-up. Acute thalamic stroke is a specific clinical picture that accurately predicts a small artery disease in the posterior circulation. The 4 arterial thalamic territories correspond well clinically to 4 different syndromes. Acute thalamic infarction appears to predict an overall good clinical recovery.     

Bilateral paramedian thalamic infarction with hypothalamic dysfunction

Unilateral thalamic lesions cause transient or permanent behavioral, sensory and oculomotor disturbances; bilateral lesions of thalamus result in more severe and longer lasting symptoms. We present an atypical case of bilateral paramedian thalamic infarct with concomitant hypothalamic dysfunction. The only risk factor of ischaemic stroke found in the patient was a short lasting episode of atrial fibrillation. Bilateral paramedian thalamic infarcts may result from occlusion of one paramedian thalamic artery, which arises from the posterior cerebral artery, either with separated or with a common trunk, thus supplying the thalamus bilaterally. Independently of anatomical variants of thalamus blood supply, the most probable cause of infarct in our patient was unilateral or bilateral occlusion of the posterior cerebral artery by cardioembolism, probably in the course of basilar artery occlusion. Hypothalamic dysfunction may accompany thalamic infarcts; thus hypothalamo-pituitary function should be routinely assessed in bithalamic infarcts.     

"Malignant" carotid artery dissection

PURPOSE: Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation. PATIENTS AND METHODS: We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries. CONCLUSIONS: "Malignant" carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.     

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.     

Multiple acute infarcts in the posterior circulation.

OBJECTIVE--to evaluate clinical, radiological, and prognostic features of patients with multiple acute infarcts in remote arterial territories of the posterior circulation. DESIGN--Data analysis from a prospective acute stroke registry in a community based primary care centre using a standard protocol including MRI and MRA. RESULTS--In three and a half years, 27 of the 236 patients (11%) with posterior circulation stroke had multiple acute infarcts in the posterior circulation as shown by gadolinium enhancement on MRI. Eighteen patients had multiple infratentorial and supratentorial infarcts including the cerebellum and posterior cerebral artery territory, with coexisting brainstem involvement in seven patients. Fourteen patients had a rostral basilar artery syndrome and cerebellar signs; four patients had a visual field defect with cerebellar signs. Causes were vertebral (six) or basilar (four) artery atheromatosis, and cardioembolism (four). Seven patients had multiple acute infarcts in the posterior circulation of the cerebellum and lower brainstem. Brainstem and cerebellar signs were found in most patients (five); aetiologies were small vessel disease (four), cardioembolism (one), and vertebral artery dissection (one). Two patients with large artery atheromatosis had multiple acute infarcts in the posterior circulation in the brainstem and posterior cerebral artery territory. One month after stroke more than 25% of the patients were dependent or had died. There was no difference in the outcome between the three groups, and recovery was linked to the size of infarcts rather than to a high number of infarcts. CONCLUSIONS--multiple acute infarcts in the posterior circulation usually involve the cerebellum. Simultaneous brainstem and posterior cerebral artery territory infarcts sparing the cerebellum are uncommon. They can be suspected clinically before neuroimaging, mainly when supratentorial and infratentorial infarcts coexist. This may be important, because different patterns of infarction are associated with different causes of stroke.     

Hyperacute cognitive stroke syndromes

Cognitive syndromes are common clinical manifestations of hyperacute stroke and may be the single or dominant presenting features. They are related to acute dysfunction of complex integrated distributed functional networks serving different cognitive domains. The most common cortical syndromes include nonfluent or fluent aphasia, neglect, collor agnosia, pure alexia and Balint's syndrome. Disturbances of declarative memory are common following posterior cerebral artery and thalamic strokes. Abulia can follow thalamic, caudate and capsular lesions. Intraventricular and subarachnoid haemorrhages can cause preeminent neuropsychological changes. Disorientation is present in about 40 % of acute stroke patients and delirium complicates the course of 25 % of acute strokes. Some hyperacute cognitive stroke syndromes are useful indicators of later disability. Cognitive syndromes may pose special difficulties to neurology residents, unless formal teaching in neuropsychology and psychiatry is included in their training programs. Received: 25 April 2001, Accepted: 30 April 2001     

Diffusion-weighted magnetic resonance imagings at the acute stage in two patients with spectacular shrinking deficit due to cardioembolic stroke]

We report diffusion-weighted magnetic resonance imagings (DWI) at the acute stage of two patients with spectacular shrinking deficit (SSD) due to cardioembolic stroke. Patient 1 was a 74-year-old woman with atrial fibrillation (Af) who had been admitted for acute cholecystitis. She abruptly developed consciousness disturbance, global aphasia and right hemiparesis. Her neurological symptoms rapidly improved 30 minutes after onset, and completely disappeared in four hours. Patient 2 was a 84-year-old woman with Af who had been on medication of warfarin potassium for three years. She abruptly developed consciousness disturbance and left hemiplegia. Her neurological symptoms rapidly improved 90 minutes after onset, and almost completely disappeared in ten hours. Their conditions were consistent with SSD in acute cardioembolic stroke. DWI of Patient 1 taken 27 hours after onset showed hyperintense signal areas in the insular and temporal cortices of the left middle cerebral artery territory, and in the parietal cortex corresponding to the border zone between the territories of the left middle cerebral artery and posterior cerebral artery. DWI of Patient 2 taken 39 hours after onset showed hyperintense signal areas in the insular and frontal cortices of the right middle cerebral artery territory, and in the parietal cortex corresponding to the border zone between the territories of the right middle cerebral artery and posterior cerebral artery. They indicated multifocal ischemic injuries at the acute stage. The T2-weighted MRI of Patient 2 showed a slight hyperintense signal area only in the right parietal cortex, but the fluid-attenuated inversion recovery (FLAIR) in both patients showed no abnormal signals in the corresponding areas. To our knowledge, ischemic lesions in DWI of SSD at the acute stage after rapid recovery have not been reported previously. DWI is useful in SSD for detecting ischemic injuries of cardioembolic origin at the early stage.     

Intra-arterial thrombolysis of embolic middle cerebral artery using collateral pathways

BACKGROUND AND PURPOSE: Cervical internal carotid artery (ICA) occlusion associated with middle cerebral artery (MCA) embolic occlusion requires prompt revascularization to prevent devastating stroke. With the advent of endovascular techniques for chemical and mechanical thrombolysis, the clinical outcome of patients with major arterial occlusions will improve. Finding the most expedient pathway to the site of end organ occlusion for thrombolysis is important. METHODS: We present two cases of acute stroke secondary to thrombotic occlusion of the cervical ICA associated with MCA embolic occlusion treated with intra-arterial thrombolysis via catheter navigation through the posterior communicating artery to the site of MCA arterial occlusion. No attempt was made to transverse the occluded ICA. RESULTS: Near complete restoration of flow was achieved in one patient and minimal vessel reopening was observed in the other patient. Both patients had good outcomes. CONCLUSION: Intra-arterial thrombolysis via Circle of Willis collaterals such as the posterior communicating artery for the treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery is a therapeutic option. This treatment option avoids the potential complications of navigating through an occluded proximal internal carotid artery and may expedite reopening of the MCA.     

Isolated intracranial fibromuscular dysplasia of the posterior cerebral artery

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory arterial disease that most commonly affects the renal and internal carotid arteries, but intracranial FMD is very rare. We report a patient with FMD involving the posterior cerebral arteries (PCAs). A 24 year old female was presented with a 4 day history of right homonymous hemianopsia with throbbing headache in the left temporo-occipital area. The brain magnetic resonance imaging (MRI) revealed an acute ischemic stroke in the left PCA territory, while the Time of Flight (TOF) magnetic resonance angiogram (MRA) showed segmental luminal irregularities in the left proximal PCA. The conventional angiogram revealed the “string of beads” appearance, a characteristic that is pathognomonic for FMD. The patient’s inhospital clinical course was stable, while there was no recurrence of stroke. This is the second report of FMD of the PCA. Notwithstanding incredibly rare incidences of isolated intracranial FMD and nonspecific findings of MRA, such a pathophysiology should be considered as the cause for a stroke in young patients, especially those with no cardiovascular risk factor.     

Paramedian thalamic and midbrain infarcts: Clinical and neuropathological study

The clinical and neuropathological findings in 28 cases of paramedian thalamic and midbrain infarcts are reported. The 4 instances of unilateral paramedian thalamic infarct were characterized by mood and behavioral changes, limitation of the infarct to the center of the anatomical paramedian territory, and symmetrical configuration of the paramedian thalamic arteries. Basilar artery occlusion was found in 1 patient. The 5 cases of bilateral paramedian thalamic infarcts were characterized by disturbances of consciousness and behavior, extension of the infarct (to the mammillothalamic tracts in 4 cases, the red nuclei in 3, and the hypothalamus in 2), and a variable paramedian thalamic arterial pattern. The arterial pattern was symmetrical in 2 cases, asymmetrical in 1, and unilateral in 1. The basilar artery was occluded in 1 case, the basilar communicating and posterior cerebral arteries in 1, and a third patient had occlusion involving an aneurysm of the basilar artery. The 19 patients with paramedian thalamopeduncular infarcts had marked disturbances of consciousness (hypersomnia, deep coma, akinetic mutism) associated with ocular motility changes. Later, abnormal movements—always delayed—and memory, disturbances were observed in some. Thalamic changes were restricted to the paramedian territory in only 3 cases. The arterial pattern was symmertical in 5. The basilar and posterior cerebral arteries were occluded in 4 patients each. Paramedian infarcts were rarely found as isolated lesions and were always bilateral when there was only one arterial pedicle. The paramedian thalamic pedicle can supply the polar thalamic territory.     

Infarcts presenting with a combination of medial medullary and posterior inferior cerebellar artery syndromes

Cerebellar and medial medullary infarctions are well-known vertebrobasilar stroke syndromes. However, their development in a patient with distal vertebral artery occlusion has not been previously reported. A 49-year-old man with longstanding hypertension suddenly developed vertigo, right-sided Horner syndrome, and left-sided weakness. An MRI of the brain showed acute infarcts in the right inferior cerebellum (posterior inferior cerebellar artery territory) and the right upper medial medulla (direct penetrating branches of vertebral artery). Magnetic resonance angiogram showed occlusion of the distal vertebral artery on the right side. Atherothrombotic occlusion of the distal vertebral artery may cause this unusual combination of vertebrobasilar stroke.     

Ischemic infarct in childhood secondary to internal carotid artery dissection. Report of a case

A previously healthy 6-year-old boy, suddenly developed a complete right hemiparesis and dysarthria while playing at school without any history of trauma. All laboratory examinations were normal except for CT brain scan that revealed a small ischemic infarct in the left middle cerebral artery territory. Four vessel cerebral angiography demonstrated a left internal carotid artery dissective obstruction while filling of the right or left vertebral artery resulted in the simultaneous retrograde appearance of the respective middle cerebral artery possibly via the posterior communicating artery. In contrast to the literature data, the patient showed a significant recovery with conservative treatment. This uncommon stroke type in children and the possible protective role of the posterior communicating artery's collateral are further discussed.