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Vertebrobasilar and Posterior Cerebral Arteries
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Posterior Cerebral Artery In about 70 percent of persons, both posterior cerebral arteries are formed by the bifurcation of the basilar artery, and only thin posterior communicating arteries join this system to the internal carotid arteries In 20 to 25 percent, one posterior cerebral artery arises from the basilar in the usual way, but the other arises from the internal carotid, a so-called persistent fetal circulation; in the remainder, both arise from the corresponding carotids The con guration and branches of the proximal segment of the posterior cerebral artery (P1 segment) are illustrated in Figs 34-6, 34-8, and 34-9 The interpeduncular branches, which arise
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Ant cerebral A Int carotid A
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Ant choroidal A Post communicating A Cerebral peduncle Red nucleus 3rd nerve nucleus Sup colliculus C Post cerebral A B Peduncular arteries Ant temporal A Thalamo-geniculate A Midbrain (thalamo) perforating A Long quadrigeminal A Post temporal A Visual cortex Calcarine A
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Figure 34-8 Inferior aspect of the brain showing the branches and distribution of the posterior cerebral artery and the principal anatomic structures supplied Listed below are the clinical manifestations produced by infarction in its territory and the corresponding regions of damage
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Signs and symptoms
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Structures involved Central territory
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Thalamic syndrome: sensory loss (all modalities), spontaneous pain and dysesthesias, choreoathetosis, intention tremor, spasms of hand, mild hemiparesis Thalamoperforate syndrome: (1) superior, crossed cerebellar ataxia; (2) inferior, crossed cerebellar ataxia with ipsilateral third nerve palsy (Claude syndrome) Weber syndrome third nerve palsy and contralateral hemiplegia Contralateral hemiplegia Paralysis or paresis of vertical eye movement, skew deviation, sluggish pupillary responses to light, slight miosis and ptosis (retraction nystagmus and tucked-in eyelids may be associated) Contralateral ataxic or postural tremor Decerebrate attacks
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Ventral posterolateral nucleus of thalamus in territory of thalamogeniculate artery Involvement of the adjacent subthalamic nucleus or its pallidal connections results in hemiballismus and choreoathetosis Dentatothalamic tract and issuing third nerve
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Issuing third nerve and cerebral peduncle Cerebral peduncle Supranuclear bers to third nerve, high midbrain tegmentum ventral to superior colliculus (nucleus of Cajal, nucleus of Darkschevich, rostral interstitial nucleus of the MLF, and posterior commissure) Dentatothalamic tract ( ) after decussation Precise site of lesion unknown Damage to motor tracts between red and vestibular nuclei
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Peripheral territory Homonymous hemianopia Calcarine cortex or optic radiation; hemiachromatopsia may be present Macular or central vision is preserved if posterior striate area is spared Bilateral occipital lobe, possibly with involvement of parieto-occipital region
Bilateral homonymous hemianopia, cortical blindness, unawareness or denial of blindness; achromatopsia, failure to see toand-fro movements, inability to perceive objects not centrally located, apraxia of ocular movements, inability to count or enumerate objects Dyslexia without agraphia, color anomia Memory defect Topographic disorientation and prosopagnosia Simultagnosia Unformed visual hallucinations, metamorphopsia, teleopsia, illusory visual spread, palinopsia, distortion of outlines, photophobia
Dominant calcarine lesion and posterior part of corpus callosum Lesion of inferomedial portions of temporal lobe bilaterally; occasionally of the dominant side only Nondominant calcarine and lingual gyri, usually bilateral Dominant visual cortex, sometimes bilateral Calcarine cortex
Note: Tremor in repose has been omitted because of the uncertainty of its occurrence in the posterior cerebral artery syndrome Peduncular hallucinosis may occur in thalamicsubthalamic ischemic lesions, but the exact location of the lesion is unknown
e c 8 P3 b 7 a P2 6 Cp 5 4 9 P4 a
d c b B a
3 P1 32 1 Cr A 1 4 2a 2b 5b 5a
Figure 34-9 The posterior cerebral and basilar arteries (Reproduced by permission from Krayenbuhl and Yasargil)
Figure 34-9A; Posterior cerebral artery A Circular or proximal segment (1) Paramedian arteries (interpeduncular, intercrural, perforating) (2) Quadrigeminal arteries (3) Thalamic arteries (medial and lateral)
Regions of vascular supply
Substantia nigra, red nucleus, mammillary body, oculomotor nerve, trochlear nerve Quadrigeminal bodies Central nucleus, medial nucleus, ventrolateral nucleus of the thalamus, pulvinar, lateral geniculate body, internal capsule (posterior portion) Epithalamus, thalamus, choroid plexus, pineal gland Tuber cinereum, cerebral peduncle, ventral nuclei of the thalamus, nuclei of the hypothalamus, optic chiasm Hippocampal gyrus, lateral geniculate body, pulvinar, dentate fascia, hippocampus, anterior basal cortex of the temporal lobe, choroid plexus of the temporal horn, trigone, dorsolateral nuclei of the thalamus
(4) Medial posterior choroidal arteries (5) Premammillary arteries (of the posterior communicating artery) (6) Peduncular artery (7) Lateral posterior choroidal arteries (anterior and posterior)
B Cortical or distal segment (8) Lateral occipital artery (a) Anterior temporal arteries (b) Middle temporal arteries (c) Posterior temporal arteries (9) Medial occipital artery (a) Dorsal callosal artery (b) Posterior parietal artery (c) Occipitoparietal artery (d) Calcarine arteries (e) Occipitotemporal artery Figure 34-9B; Basilar artery B Basilar artery Cr Posterior communicating artery (1) Thalamic arteries (2a) Medial posterior choroidal artery (2b) Lateral posterior choroidal artery (3) Dorsal callosal artery (4) Medial occipital artery (a) Posterior parietal arteries (b) Occipitoparietal arteries (c) Calcarine arteries (5a) Anterior and middle temporal arteries (5b) Posterior temporal artery
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