Introduction: Posterior cerebral artery (PCA) infarctions are usually small in extent and are thus expected to follow a benign course. Malignant unilateral PCA infarctions have not been previously reported.
Methods: Retrospective review of three cases of unilateral PCA infarction exhibiting malignant progression, with cerebral edema-related mass effect, increased intracranial pressure, and transtentorial herniation.
Results: Patient 1 was successfully managed medically using intravenous hypertonic saline and had a favorable functional outcome. Patients 2 and 3 both underwent decompressive hemicraniectomy after clinical signs of transtentorial herniation developed, and both died in the acute phase from malignant intracranial hypertension. In each instance, PCA occlusion was accompanied by a flow-limiting lesion in the internal carotid or middle cerebral artery.
Conclusions: Congenital and/or acquired variability in the distribution and extent of territory supplied by the PCA may lead to the rare syndrome of malignant PCA infarction. Patients suffering a PCA infarct should be followed closely and offered early surgical decompression in the event of malignant conversion.
Patient Care: This manuscript will have an impact by highlighting a rare clinical entity in malignant PCA infarctions that could benefit greatly from early surgical decompression. It is an atypical syndrome that can occur in patients with certain congenital and acquired vascular risk factors that are discovered via cerebrovascular imaging. Certain patients may benefit in the future from increased scrutiny for malignant conversion of their PCA strokes.
Learning Objectives: 1) Understand the congenital variability in vascular territories supplied by cerebral vessels.
2) Identify risk factors for the development of malignant PCA infarction.
3) Appreciate the need for increased surveillance for malignant conversion of PCA infarctions in patients with certain vascular risk factors.
4) Consider decompressive hemicraniectomy as a life-saving treatment in these rare clinical entities.
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