Unusual vascular events in the territory of the posterior cerebral artery.

ABSTRACT

PIP: 10 cases are presented in which a posterior cerebral artery (PCA) deficit developed suddenly in dramatic fashion with headache, visual symptoms, sensory and motor deficits, and signs of 3rd nerve involvement. There were 9 females and 1 male, ranging in age from 18-51 years with 7 cases under age 35. In 9 of the 10 patients, headache was prominent at the onset; 6 patients reported being dramatically stricken with a severe, sharp localized pain in the forehead or occiput. Visual symptoms were prominent at the onset in 7 patients -- 4 patients experiencing blindness and 3 patients a hemianoptic deficit. Hemisensory symptoms or deficit occurred in 6 instances, a hemiparesis in 3, combined weakness and sensory deficit in 1. Evidence of a 3rd nerve palsy was found in 3 cases. A persisting neurologic deficit occurred in 10 cases -- visual field defect, 6 cases; hemiplegia, 1; slight weakness, 1; and a sensory deficit, 2. A movement disorder developed on the involved side in 7 cases. Evidence of infarction in 1 or both occipital lobes was obtained in 6 patients. 1 patient did not have impaired visual fields, and the other 3 were examined before the days of nuclear medicine and CT scanning. Conventional angiography was performed in 8 patients with the following results: retrothalamic occlusion of 1 PCA (1 patient); distal occlusion of 1 PCA (1 patient); retrothalamic narrowing of 1 PCA (1 patient); irregularity of the wall of the upper basilar artery and both PCAs (1 patient); and in 4 angiography was normal. A digital subtraction angiogram in 1 patient was normal; 1 patient did not have an arteriogram. A history of accompanied migraine was obtained in 3 patients. 1 patient was pregnant; 1 patient was 3 months postpartum. 1 patient was taking oral contraceptives; 1 patient had taken 1 contraceptive pill, and 1 patient was receiving injections of estrogen. These cases represent involvement of the territory of the PCA. They share the same features in varied combinations. The onset or evolution is dramatic, distinctive, or alarming. The cases do not fall easily into any commonly recognized category of cerebrovascular disturbances. The process that most likely applies to this group of cases is migraine. If that is so, the term "catastropic migraine" or "cataclysmic migraine" may have some currency. If it is assumed that the process is ischemic and since vascular obstruction was found in 2 cases, the possibility of using heparin therapy might be considered. In most of the present cases, steroid therapy was used to control brain swelling. If the pathologic process is temporary vasospasm, the use of hemodilution or hyperbaric oxygen could be an option.