Kristen Hudson, MD Valerie Biousse , MD

Posterior Cerebral Artery Infarction from Vertebral Artery Dissection, Presenting with Homonymous Hemianopia Kristen Hudson, MD Valerie Biousse, MD

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

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

Humphrey Visual Fields (HVF) LEFT EYE RIGHT EYE Figure 1a Figure 1b Complete Left Homonymous Hemianopia

Brain MRI (8 hours after symptom onset)Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC) DWI ADC Axial images, progressing inferior to superior – 1 of 4 Figure 2a Figure 2b 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)

Brain MRI (8 hours after symptom onset)Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC) DWI ADC Axial images, progressing inferior to superior – 2 of 4 Figure 3a Figure 3b 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)

Brain MRI (8 hours after symptom onset)Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC) DWI ADC Axial images, progressing inferior to superior – 3of 4 Figure 4a Figure 4b Note bright on DWI (red arrows) and corresponding dark on ADC (green arrows) indicating acute infarction in right occipital lobe and thalamus

Brain MRI (8 hours after symptom onset)Diffusion Weighted Images (DWI) and Apparent Diffusion Coefficient (ADC) DWI ADC Axial images, progressing inferior to superior – 4of 4 Figure 5a Figure 5b Note bright on DWI (red arrows) and corresponding dark on ADC (green arrows) indicating acute infarction in right occipital lobe and thalamus

MRA Head with contrast– Source Images Axial images, progressing inferior to superior – 1 of 2 R ICA L ICA L ICA R ICA R ICA L ICA Figure 6a Figure 6b 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 ICAsand right VA (red arrows). Figure 6c

MRA Head with contrast– Source Images Axial images, progressing inferior to superior – 2 of 2 Basilar Artery L PCA R PCA L PCA L PCA R PCA Figure 7a Figure 7b Figure 7c 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).

MRA Head with contrast– 3D reconstructions Rotation: view from above Rotation: view from the back ACAs ACAs L MCA L MCA R MCA R MCA L PCA R ICA L ICA Basilar A R PCA R ICA L ICA R VA L VA R VA L VA Figure 8a Figure 8b 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).

Head CT without contrast (2.5 weeks later) Axial images, progressing inferior to superior Figure 9a Figure 9b Figure 9c Hypodensity(red arrows) in right occipital and inferior temporal lobes corresponding to old infarction (2.5 weeks) Figure 9d

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

Kristen Hudson, MD Valerie Biousse , MD

Kristen Hudson, MD Valerie Biousse , MD

Presentation Transcript

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