1. Definition³
1.1. P1: Occlusion of proximal PCA segment
1.2. P2: Occlusion of distal PCA segment
2. Epidemiology⁴
2.1. estimated between 5%-10%
2.2. MC embolism
2.3. thrombus
2.4. atherosclerosis
2.5. small artery disease
2.6. dissection of PCA
2.7. RF: HTN, DM, A-fib, dyslipidemia, sickle cell disease, smoking, ETOH, low physical activity
3. Pathophysiology¹
3.1. Restrict blood supply to⁴:
3.1.1. occipital lobe
3.1.2. inferomedial temporal lobe
3.1.3. large portion of thalamus
3.1.4. upper brainstem and midbrain
4. Proper Documentation²
4.1. Normal Findings
4.1.1. General Inspection:
4.1.2. JD is 25 yo F is a Caucasian female who appears healthy, happy and well-groomed with no apparent signs of distress. Her facial makeup is symmetrical. She remains pleasant and cooperative during the exam and responds to questions with direct eye contact and an expressive affect. She is alert and oriented to person, place and time. She is right handed.
4.1.3. Memory: Repeated a series of 7 digits. Recalled 3 objects after 5 minutes (watermelon, chair, bird) and events of past (9/11/2001).
4.1.4. Language: Followed verbal and written directions, demonstrated listening, reading and comprehension skills. Named an object (pen). Wrote name (Jane).
4.1.5. Speech: High quality labial (pa), lingual (la), and posterior pharynx/larynx (ga) voice sounds.
4.1.6. Higher Cortical Function: Expressed general knowledge (days in a week, weeks in a month, months in a years). Calculated serial 3’s from 33 to 24. Interpreted a proverb (the grass is greener on the other side). Judgement scenario answered appropriately (would mail postcard). Communicated insight (reason for being here).
4.1.7. Non-Dominant Hemisphere Function: Accurately replicated drawing of clock at 3 o’clock and a single house. Correctly placed cap back on pen. No hemineglect or inattention noted. Correctly touched L index finger to R shoulder.
4.1.8. CN1: + Sense of peppermint small b/l.
4.1.9. CN2: Near vision with Rosenbaum card 20/20 OS, 20/20 OD, 20/20 OU/ Full temporal, nasal, and peripheral field vision by confrontation b/l. Fundoscopic exam with red reflex, clear lens, pale and yellow optic disc, and visible vessels b/l. No hemorrhages, AV nicking, exudates or papilledema b/l.
4.1.10. CN3, CN4, CN6: - Ptosis. PEERLA. EOMs intact.
4.1.11. CN7: Facial expression symmetric with smiling, closing eyes, furrowing eyebrows and puffing cheeks.
4.1.12. CN5: + Corneal reflex and nasal tickle. Muscle strength 5/5 b/l for masseter and temporalis muscles.
4.1.13. CN8: + Finger rub in R, ear, L ear, and together. - Weber and Rinne test with AC>BC.
4.1.14. CN9, CN10: Symmetric rise of palate and uvular with high quality phonation. + Gag reflex. Swallowing is coordinated.
4.1.15. CN11: Muscle strength 5/5 b/l of sternocleidomastoid and trapezius muscles.
4.1.16. CN12: Tongue protrusion midline and symmetric without atrophy or fasciculation. Tongue strength 5/5.
4.1.17. Sensory: Sensation to light touch, pinprick and temperature over face, chest, back, abdomen, bilateral arms and legs intact. Demonstrated Stereognosis (identified penny), Graphesthesia (recognized number 3 written on palm), Point localization (R upper arm), Extinction (L forearm and R thigh), Two-point discrimination at 4 mm.
4.1.18. Motor: No atrophy or hypertrophy or fasciculations of muscles. 5/5 muscle strength in deltoid, biceps, brachioradialis, triceps, wrist extensors, wrist flexors and grip strength. 5/5 muscle strength in Hip flexors, Hip abductors, Hip adductors, quadriceps, hamstrings, dorsiflexors, plantar flexors.
4.1.19. Coordination: Finger to nose, finger to examiner’s finger, heel to shin performed accurately. Accurately, rapidly, and smoothly demonstrated bilateral hand flip, finger to thumb and toe tap.
4.1.20. Superficial Reflexes: Abdominal response of umbilicus toward each area of stimulation equal bilaterally.
4.1.21. Deep Reflexes: 2+ and symmetric. – Babinski sign.
4.1.22. Primitive Reflexes: – Myerson’s, palmomental reflex, grasp reflex, snout reflex and root reflex.
4.1.23. Gait and Station: Gait coordinated and smooth with toe, heel and tandem walk. Maintains balance with monopedal stance and Romberg test. No pronator drift.
4.1.24. Meningeal irritation: No nuchal rigidity. – Brudzinski’s sign. – Kernig’s sign.
4.2. Abnormal Findings (ex: R-sided PCA Stroke)
4.2.1. JD is 25 yo F is a Caucasian female who appears concerned, drowsy and uncomfortable. Her facial makeup is symmetrical. She remains fearful but cooperative during the exam and responds to questions with slurred speech, a slight upward gaze and a flattened affect. She is alert and oriented to person, place and time.
4.2.2. Memory: Repeated a series of 7 digits. Unable to recall 3 objects after 5 minutes (watermelon, chair, bird). Recalled events of past (9/11/2001).
4.2.3. Language: Unable to follow written directions or reading comprehension. Followed verbal directions. Listening and comprehension skills intact. Named an object (pen). Wrote name (Jane).
4.2.4. Speech: High quality labial (pa), lingual (la), and posterior pharynx/larynx (ga) voice sounds.
4.2.5. Higher Cortical Function: Expressed general knowledge (days in a week, weeks in a month, months in a years). Calculated serial 3’s from 33 to 24. Interpreted a proverb (the grass is greener on the other side). Judgement scenario answered appropriately (would mail postcard). Communicated insight (reason for being here).
4.2.6. Non-Dominant Hemisphere Function: Accurately replicated drawing of clock at 3 o’clock and a single house. Correctly placed cap back on pen. No hemineglect or inattention noted. Correctly touched L index finger to R shoulder.
4.2.7. CN1: + Sense of peppermint small b/l.
4.2.8. CN2: Near vision with Rosenbaum card 20/20 OS, 20/20 OD, 20/20 OU. Limited L temporal and R nasal field vision by confrontation. Pupillary light reflex intact. Fundoscopic exam with red reflex, clear lens, pale and yellow optic disc, and visible vessels b/l. No hemorrhages, AV nicking, exudates or papilledema b/l.
4.2.9. CN3, CN4, CN6: - Ptosis. PERRLA. EOMs intact.
4.2.10. CN5: + Corneal reflex and nasal tickle. Muscle strength 3/5 for R masseter and temporalis muscles.
4.2.11. CN7: Facial expression asymmetric with smiling, closing eyes, furrowing eyebrows and puffing cheeks.
4.2.12. CN8: + Finger rub in R, ear, L ear, and together. - Weber and Rinne test with AC>BC.
4.2.13. CN9, CN10: Symmetric rise of palate and uvula with high quality phonation. + Gag reflex. Swallowing is coordinated.
4.2.14. CN11: Muscle strength 3/5 for L sternocleidomastoid and trapezius muscles.
4.2.15. CN12: Tongue protrusion towards L side without atrophy or fasciculation. Tongue strength 4/5.
4.2.16. Sensory: Decreased sensation to light touch, pinprick and temperature over L face, chest, back, abdomen, bilateral arms and legs; R sided sensation intact. Unable to test stereognosis, graphesthesia, point localization, extinction or two-point discrimination due to weakness of L extremities.
4.2.17. Motor: No atrophy or hypertrophy. Presence of hemiballismus of L extremities. 3/5 muscle strength in L sided deltoid, bicep, brachioradialis, tricep, wrist extensor, wrist flexor and grip strength. 3/5 muscle strength in L sided hip flexor, Hip abductor, Hip adductor, quadricep, hamstring, dorsiflexor, plantar flexor. Comparable muscle groups on R side of UE and LE muscle strength 5/5.
4.2.18. Coordination: Finger to nose, finger to examiner’s finger weak and slow on L side. Unable to test hand flip and toe tap. Accurately, rapidly, and smoothly finger to thumb on R hand, weak slow on L side.
4.2.19. Superficial Reflexes: Abdominal response of umbilicus toward each area of stimulation equal bilaterally.
4.2.20. Deep Reflexes: 2+ and symmetric. – Babinski sign.
4.2.21. Primitive Reflexes: – Myerson’s, palmomental reflex, grasp reflex, snout reflex and root reflex.
4.2.22. Gait and Station: Unable to test due to L leg weakness
4.2.23. Meningeal irritation: No nuchal rigidity. – Brudzinski’s sign. – Kernig’s sign.
5. Signs/Symptoms
5.1. Contralateral homonymous hemianopia w/ macular sparing 5
5.2. Contralateral hemisensory loss and hemi-body pain (thalamic infarction)¹
5.3. Contralateral hemiballismus³
5.4. Alexia w/o agraphia³
5.5. Aphasia (large infarction involving parietal or temporal lobe)⁴
5.6. Visual agnosia (large left PCA infarction)⁴
5.7. Ataxia³ - Contralateral ataxia or contralateral hemiplegia with CN III palsy
5.8. Amnesia (transient)³
5.9. Upward gaze and drowsiness; often abulia³
5.10. cortical blindness with reserved pupillary light reaction; May be unaware of blindness (bilateral distal PCA infarction)³
5.11. Achromatopsia⁴
5.12. Coma, unreactive pupils, bilateral pyramidal signs, decerebrate rigidity (Extensive infarct of midbrain/subthalamus occurring with bilateral proximal PCA occlusion)³
6. Differential Diagnosis⁴
6.1. MCA Stroke
6.2. ACA Stroke
6.3. Vertebral artery occlusion
6.4. basilar artery occlusion
6.5. hypoglycemia
6.6. subarachnoid hemorrhage
6.7. intracranial hemorrhage
6.8. Intracranial hypertension
6.9. traumatic brain injury
6.10. TIA
6.11. brain tumor/mass
6.12. vasculitis
6.13. migraine
7. Workup Labs/Diagnostics⁴
7.1. Head CT
7.1.1. angiography
7.1.2. without contrast*
7.1.2.1. ex. Left PCA infarction (axial view)¹
7.2. vitals
7.3. glucose finger stick
7.4. CBC
7.5. CMP
7.6. PT/PTT/INR
7.7. Lipid panel
7.8. Hemoglobin A1c
7.9. Cardiovascular r/o
7.9.1. EKG
7.9.2. Troponin
8. Treatment
8.1. tPA (within 4 hours of neurological deficit)⁴
8.2. endovascular treatment¹
8.2.1. stenting
8.2.2. angioplasty
8.2.3. embolectomy