Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Posterior circulation cerebrovascular syndromes

Louis R Caplan, MD
Section Editor
Jose Biller, MD, FACP, FAAN, FAHA
Deputy Editor
John F Dashe, MD, PhD


Twenty percent of ischemic events in the brain involve posterior circulation (vertebrobasilar) structures. This topic will review the major clinical syndromes associated with posterior circulation ischemia related to stenosis or occlusion of the large aortic arch, neck, and intracranial arteries. These arteries are the innominate and subclavian arteries in the chest, the vertebral arteries in the neck, and the intracranial vertebral, basilar, and posterior cerebral arteries.

The evaluation and management of acute ischemic stroke (including stroke involving the posterior circulation) are discussed separately. (See "Initial assessment and management of acute stroke" and "Reperfusion therapy for acute ischemic stroke" and "Neuroimaging of acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack".)


The most common causes of posterior circulation large artery ischemia are atherosclerosis, embolism, and dissection. Dolichoectasia (elongation and tortuosity) of the vertebral and basilar arteries is another occasional cause.

About one-third of posterior circulation strokes are caused by occlusive disease within the large neck and intracranial arteries, which are the vertebral arteries in the neck and the intracranial vertebral, basilar, and posterior cerebral arteries [1-4].

The proximal portion of the vertebral artery in the neck is the most common location of atherosclerotic occlusive disease within the posterior circulation [1-5]. Atherosclerosis of the intracranial vertebral arteries and of the basilar artery is also common. (See "Intracranial large artery atherosclerosis".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 14, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Caplan LR, Wityk RJ, Glass TA, et al. New England Medical Center Posterior Circulation registry. Ann Neurol 2004; 56:389.
  2. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005; 352:2618.
  3. Caplan LR. Posterior Circulation Disease: Clinical Findings, Diagnosis, and Management, Blackwell Science, Boston 1996.
  4. Caplan L. Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture-2000. Stroke 2000; 31:2011.
  5. Wityk RJ, Chang HM, Rosengart A, et al. Proximal extracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol 1998; 55:470.
  6. Brewster DC, Moncure AC, Darling RC, et al. Innominate artery lesions: problems encountered and lessons learned. J Vasc Surg 1985; 2:99.
  7. Labauge R, Boukobza M, Pagès M, et al. [Occlusion of the vertebral artery (100 personal cases)]. Rev Neurol (Paris) 1987; 143:490.
  8. Caplan LR, Amarenco P, Rosengart A, et al. Embolism from vertebral artery origin occlusive disease. Neurology 1992; 42:1505.
  9. Caplan LR. Dissections of brain-supplying arteries. Nat Clin Pract Neurol 2008; 4:34.
  10. Rosengart A, Hedges TR 3rd, Teal PA, et al. Intermittent downbeat nystagmus due to vertebral artery compression. Neurology 1993; 43:216.
  11. Choi KD, Choi JH, Kim JS, et al. Rotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke 2013; 44:1817.
  12. Choi KD, Shin HY, Kim JS, et al. Rotational vertebral artery syndrome: oculographic analysis of nystagmus. Neurology 2005; 65:1287.
  13. Caplan LR, Baquis GD, Pessin MS, et al. Dissection of the intracranial vertebral artery. Neurology 1988; 38:868.
  14. Searls DE, Pazdera L, Korbel E, et al. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol 2012; 69:346.
  15. Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain 2003; 126:1864.
  16. Morrow MJ, Sharpe JA. Torsional nystagmus in the lateral medullary syndrome. Ann Neurol 1988; 24:390.
  17. Brandt T, Dieterich M. Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex. Ann Neurol 1994; 36:337.
  18. Keane JR. Ocular tilt reaction following lateral pontomedullary infarction. Neurology 1992; 42:259.
  19. Matsumoto S, Okuda B, Imai T, Kameyama M. A sensory level on the trunk in lower lateral brainstem lesions. Neurology 1988; 38:1515.
  20. Tyler KL, Sandberg E, Baum KF. Medical medullary syndrome and meningovascular syphilis: a case report in an HIV-infected man and a review of the literature. Neurology 1994; 44:2231.
  21. Amarenco P, Hauw JJ. [Anatomy of the cerebellar arteries]. Rev Neurol (Paris) 1989; 145:267.
  22. Amarenco P, Hauw JJ, Hénin D, et al. [Cerebellar infarction in the area of the posterior cerebellar artery. Clinicopathology of 28 cases]. Rev Neurol (Paris) 1989; 145:277.
  23. Passero S, Filosomi G. Posterior circulation infarcts in patients with vertebrobasilar dolichoectasia. Stroke 1998; 29:653.
  24. Pico F, Labreuche J, Seilhean D, et al. Association of small-vessel disease with dilatative arteriopathy of the brain: neuropathologic evidence. Stroke 2007; 38:1197.
  25. Passero SG, Rossi S. Natural history of vertebrobasilar dolichoectasia. Neurology 2008; 70:66.
  26. Savitz SI, Ronthal M, Caplan LR. Vertebral artery compression of the medulla. Arch Neurol 2006; 63:234.
  27. Lou M, Caplan LR. Vertebrobasilar dilatative arteriopathy (dolichoectasia). Ann N Y Acad Sci 2010; 1184:121.
  28. Pico F, Labreuche J, Amarenco P. Pathophysiology, presentation, prognosis, and management of intracranial arterial dolichoectasia. Lancet Neurol 2015; 14:833.
  29. Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008; 70:2378.
  30. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40:3504.
  31. Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011; 183:E571.
  32. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20:986.
  33. Pessin MS, Gorelick PB, Kwan ES, Caplan LR. Basilar artery stenosis: middle and distal segments. Neurology 1987; 37:1742.
  34. KUBIK CS, ADAMS RD. Occlusion of the basilar artery; a clinical and pathological study. Brain 1946; 69:73.
  35. Labauge R, Pages M, Marty-Double C, et al. [Occlusion of the basilar artery. A review with 17 personal cases (author's transl)]. Rev Neurol (Paris) 1981; 137:545.
  36. Ferbert A, Brückmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke 1990; 21:1135.
  37. Voetsch B, DeWitt LD, Pessin MS, Caplan LR. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol 2004; 61:496.
  38. Ropper AH. 'Convulsions' in basilar artery occlusion. Neurology 1988; 38:1500.
  39. Caplan LR. "Top of the basilar" syndrome. Neurology 1980; 30:72.
  40. Mehler MF. The neuro-ophthalmologic spectrum of the rostral basilar artery syndrome. Arch Neurol 1988; 45:966.
  41. Pessin MS, Lathi ES, Cohen MB, et al. Clinical features and mechanism of occipital infarction. Ann Neurol 1987; 21:290.
  42. Fisher CM. The posterior cerebral artery syndrome. Can J Neurol Sci 1986; 13:232.
  43. Yamamoto Y, Georgiadis AL, Chang HM, Caplan LR. Posterior cerebral artery territory infarcts in the New England Medical Center Posterior Circulation Registry. Arch Neurol 1999; 56:824.
  44. Georgiadis AL, Yamamoto Y, Kwan ES, et al. Anatomy of sensory findings in patients with posterior cerebral artery territory infarction. Arch Neurol 1999; 56:835.
  45. Hommel M, Besson G, Pollak P, et al. Hemiplegia in posterior cerebral artery occlusion. Neurology 1990; 40:1496.
  46. Benson DF, Tomlinson EB. Hemiplegic syndrome of the posterior cerebral artery. Stroke 1971; 2:559.
  47. North K, Kan A, de Silva M, Ouvrier R. Hemiplegia due to posterior cerebral artery occlusion. Stroke 1993; 24:1757.
  48. Caplan LR, Hedley-Whyte T. Cuing and memory dysfunction in alexia without agraphia. A case report. Brain 1974; 97:251.
  49. Geschwind N. Disconnexion syndromes in animals and man. I. Brain 1965; 88:237.
  50. Geschwind N, Fusillo M. Color-naming defects in association with alexia. Arch Neurol 1966; 15:137.
  51. Barton JS, Caplan LR. Cerebral visual dysfunction. In: Stroke Syndromes, 2nd edition, Bogousslavsky J, Caplan LR (Eds), Cambridge University Press, Cambridge 2001. p.87.
  52. Kertesz A, Sheppard A, MacKenzie R. Localization in transcortical sensory aphasia. Arch Neurol 1982; 39:475.
  53. Benson DF, Marsden CD, Meadows JC. The amnesic syndrome of posterior cerebral artery occlusion. Acta Neurol Scand 1974; 50:133.
  54. Ott BR, Saver JL. Unilateral amnesic stroke. Six new cases and a review of the literature. Stroke 1993; 24:1033.
  55. Damasio AR, Damasio H, Van Hoesen GW. Prosopagnosia: anatomic basis and behavioral mechanisms. Neurology 1982; 32:331.
  56. Fisher CM. Disorientation for place. Arch Neurol 1982; 39:33.