Posterior Cerebral Artery

The PCA is an old vessel, in fact emerging in the lower species prior to development of the MCA. This
makes sense because some of the areas it supplies occipital and mesial temporal lobes (besides the
tectum) are phylogenetically more well established than the bulk of frontoparieral areas now served
by the MCA. The PCA originally belongs to the anterior, carotid circulation, arising as the carotid
terminates into the cranial and caudal rami the future ACA and PCA, respectively. Transfer of the
PCA territory to the vertebrobasular circulation is a process which seems to be necessitated, from the
phylognenetic standpoint, by the relatively large volume of brain supplied in the human and other
higher species by the carotid system. In many mammals the vertebrobasilar system does not
prominently figure in PCA supply, being confined to the brainstem and cerebellum. This is the simple
phylogenetic explanation for the most common circle of Willis variant the fetal PCA named as
such when early fetal arrangement of PCA origin from the ICA persists in the adult form, which is
about 20-25% of the time. The variability in number is due to haggling over the semantics of what
exactly constitutes a fetal PCA. Is it complete absence of the P1 segment of the PCA? Is it a state
where P1 is felt to be insufficient to provide adequate PCA perfusion should the PCOM be closed? Is it
simply when the PCOM is larger than the P1? Whatever the case, you have every right to confidently
pick your own definition. The important point to appreciate is that there is no such thing as an absent
PCOM or P1. There is certainly an angiographic or MRA or CTA absence of these vessels, which
means nothing except that your equipment is not good enough to see it. They are always present in fact,
as embryologically required.

Early development of the PCA is dominated by its supply of the lateral and third ventricular choroidal
territory (the choroidal stage, as best described in Surgical Neuroangiography), together with the
Anterior Choroidal Artery. In fact, from a phylogenetic standpoint, it is the Anterior Choroidal and not
the PCA that serves as the artery to the occipital and temporal lobar areas. In the human, the Anterior
Choroidal parenchymal supply is typically restricted to its segment proximal to its plexal point (again
see dedicated page for details), with hemispheric territory transferred to the PCA. However, on
occasion the anterior choroidal retains some of its formerly extensive cortical possessions, and as such
might even be mistaken for a fetal PCA. In the vast majority of cases, however, the PCA is responsible
for the supply of the mesial Occipital, inferomesial Parietal, and inferior Temporal lobes, as well as the
choroid plexus of the lateral (together with the anterior choroidal) and third ventricles. Importantly, it
also contributes to the supply of the cerebral peduncles and the collicular plate, its phylogenetically
older territories.

Here is a beautiful image of a PCA specimen x-ray from the Yung Peng Huang collection
Also from the collection, a specimen photograph
A detail of the photograph, with additional labels (see below)
Territory, variations, images

As mentioned above, the PCA is usually responsible for the supply of the Occipital, inferomesial
Parietal, and inferior Temporal lobes, as well as the choroid plexus of the lateral (together with the
anterior choroidal) and third ventricles. Importantly, by way of the collicular or circumcollicular
arteries it also contributes to vascularization of cerebral peduncles and the collicular plate, its
phylogenetically older territories. Angiographically, the PCA is best evaluated in steep frontal
projections such as the Townes, which allow the various segments of the PCA trunk to be opened up.
In the lateral, there is frequent superimposition, which can be resolved by yawing the lateral tube to
separate the two. Stereoscopic imaging can help decide which side is which, if knowledge is otherwise
insufficient. The above image from the YPH collection, with a corresponding drawing on the left, for
reference:
A lateral image of the x-ray specimen, with colored arrows this time. Inferior thalamoperforating
arteries from the P1 segment (white) and PCOM (black). Geniculate = purple. Posterior lateral
choroidal = red (note characteristic C-shaped curve). Posterior pericalossal (a.k.a. splenial branch) =
yellow. Calcarine = pink. Parieto-occipital = green. Posterior Inferior Temporal = light blue. Middle
Inferior Temporal = dark blue. Anterior Inferior Temporal = brown
Nothing like a stroke to show what the territory was: notice large portions of the inferior mesial
temporal lobe, including the hippocampus, and parts of the thalamus, in this patient with a top of the
basilar occlusion:
Below is a typical angiographic image of the PCA. On the right, the P1 (purple) segment is smaller than
on the left (red), with streaming of unopacified blood (white) through the right PCOM visible distal to
its otherwise invisible confluence with the P1 segment.
A typical fetal PCOM, ICA injection. Various branches of the PCA are marked, including PCOM
(red) and posterior inferior temporal (yellow, green), middle temporal (black) and anterior temporal
(white) branches arising from a common trunk, with the posterior temporal one being the largest. There
is tremendous variation in how the inferior temporal branches are organized. The important part to
understand is where the branch is relation to the brain.
Left vertebral injection in the same patient. Notice a steeper Townes frontal projection, as compared
with the standard AP above. The right P1 is absent, but only angiographically. The left PCOM (red)
is transiently retrogradely opacified by the force of the injection. The portion which curves around the
brainstem is the P2. Anything distal is P3, P4, and on. Because of the fetal disposition on the right,
the lateral allows for left PCA view without superimposition. The all-important calcarine branch
(black) is the paramedian branch just above the tent (where the calcarine cortex is). Importantly, it will
be foreshortened in the Townes view because the tent will be sloping down. The parieto-occipital
branch on the other hand (pink) is less foreshortened. It is typically large and should not be mistaken for
the calcarine one.

Also notice several large posterior inferior temporal branches (yellow). Because of the shape of the
tent, which slopes down as it stretches laterally, the temporal branches will ovelap the cerebellum in
both frontal and lateral views. It is very important to understand that. The calcarine branch will never
do that in the lateral view, because the medial occipital lobe is always above the cerebellum.
Here is the same patient with the tentorium cerebelli outlined, for claritys sake
Another fetal PCOM (by my definition), on the left. A small P1 segment is present (orange).
Notice how well the left tent is outlined by the hemspheric branch of the left SCA plastered up against
it (no arrows this time). A sizable basilar fenestration is shown by the brown arrow. Also note that the
frontal left vertebral injection projection is not a Townes, but more like a Caldwell/Submental type.
Thus, all PCA branches are superimposed on each other, with no good definition, except for one the
posterior lateral choroidal branch (white arrow) rises above the rest, to where the lateral ventricle would
be.
MRA of bilateral fetal PCOMs, with corresponding hypoplasia of the basilar artery. Notice the unfused
long P1 segments above the superior cerebellar ostia (arrow). See Basilar Artery page for details
Posterior Communicating Artery Fenestration not something you see everyday. Here is one, in
association with a Trigeminal artery. So, what does that say about the embryology of the PCOM as a
caudal ramus of the ICA?
Superior Cerebellar Artery origin from the PCA

The apparent origin of the PCA from the P1 segment is, in fact, directly related to the embryology of the
basilar artery, which is formed by fusion of paired longitudinal neural arteries. The extent of fusion
determines the length of the basilar, and some of its variations. The position of the SCAs with respect
to the P1 segment is related to the degree of upper basilar fusion, with the unfused configuration
corresponding to SCA origin from the PCA. Imagine the basilar artery as a zipper:
The following variation, involving lack of basilar tip fusion, can generate a lot of confusion. Effectively,
the top of the basilar is split in two, so that one or both superior cerebellar arteries originate from the P1
segment. This variant is not, therefore, a primary superior cerebellar artery aberration, but instead a
deficiency in basilar fusion.
The third, basilar fenestration, is quite common, and usually of little clinical significance, except when
it is so short as to minic a dissection.
Basilar nonfusion extreme fenestration, a completely unzipped look. Very rare.
Origin of superior cerebellar artery at top of the basilar on the left (yellow), and from P1 segment on
the right (red arrow) seen often, can be conceptualized as a short basilar which did not undergo
enough coalescence at the top to incorporate the superior cerebellar artery.
Notice P1 origin of the right superior cerebellar artery (red) with contralateral classical disposition in

yellow
The same unfused upper basilar, with the seemingly opposite appearance of the right P1 (red arrow)
originating from the SCA. Both cases are in fact variants of deficient upper basilar fusion. P2 wash-in
(purple) is present, as well as some reflux into a dominant left PCOM (yellow). Notice abundant
pontine perforators (within red oval) in setting of bilateral PICA dominance. The smaller the AICAs,

the more perforators will be. For more details, see Basilar Artery
page.
Below is an example of an embolus from the
carotid artery into a fetal PCOM (white arrow).
Notice markedly reduced CBV values on this CT
perfusion map, indicative of a completed
infarction with no penumbra. This, unfortunately,
is too often true with occipital infarcts. The medial
occipital area is not well-supported via
leptomeningeal collaterals, being at the distal end of
both ACA and MCA territories, and cortical visual
field deficits too often show minimal to no
recovery. Also appreciate the relatively straight
shot from the supraclinoid ICA into the PCOM,
suggesting that this was the hemodynamically
preferable route for the embolus.
Calcarine Branch

Frank Netter drawing, emphasizing inferior location of the Calcarine branch in relation to the
Parietooccipital branch which is situated in the sulcus of the same name.
The temporo-occipital territory sits at the further
edge of two potential sources of supply
anteriorly from the temporo-occipital branches of
the MCA, and inferiorly from the posterior inferior
temporal artery. Here is an illustration of this
phenomenon, in a patient with the territory of
interest demarcated by the parenchymal
hemorrhage component. Both ICA and vertebral
injections are required to fully delineate the AVM,
supplied by the parieto-occipital branch of the
MCA (yellow) and posterior inferior temporal
branches of the PCA (red). Notice how far back the
branch extends on the lateral view again not to
be confused with the calcarine branches (green),
which are superimposed on the nidus in the lateral
projection. The parieto-occipital branches (white)
are medial and do not contribute to the AVM. A
normal posterior inferior temporal branch is marked
with a purple arrow
Leptomeningeal Collaterals in anterior circulation occlusion

The PCA can be very effective in leptomeningeal collateralization of the MCA and even ACA
territories. The inferior temporal branches (green) will attempt to reconstitute the upper, perisylvian
portions of the temporal lobe, while the parieto-occipital branch fills in variable territories of the
superior parietal lobule, precuneus, and possibly the posterior frontal convexity, depending on whether
or not the hemodynamic constraint affects the MCA, ACA, or both. In this way, the inferior temporal
branches can help salvage the Wernicke area. In most cases of acute occlusion, however, PCA cortical
branches are too far posterior and inferior to effectively resupply the frontal lobe, which depends on the
ACA in cases of insufficient MCA perfusion.

In this ICA embolus case, the posterior inferior temporal branch (red) and middle inferior temporal
branch (purple) leptomeningeal vessels help reconstitute a sizable portion of the temporal lobe (light
blue oval, parenchymal phase), retrogradely opacifying several inferior division temporal (green) and
inferior parietal (yellow) branches of the MCA. The parieto-occipital artery attemps to revascularise the
cuneus, reconsituting a superior mesial parietal branch (white) of the ACA (purple arrow). The extent of
collateral support in the temporal lobe territory is fairly robust. The posterior pericalossal artery (black
arrow) is normally a very poor collateral to the distal pericalossal (light blue) territory of the ACA. In
this case, a small leptomeningeal network (pink) is trying its best. Notice normal-appearing posterior
(gray), middle (brown) and anterior (orange) inferior temporal branches on the right.
Here is another example of rather effective leptomeningeal collateral response through the parieto-
occipital territory supporting the superior parietal lobule (red) and great inferior temporal support of the
MCA inferior division (green). Nearly the entire temporal lobe is adequately perfused.

Posterior Pericalossal-Pericalossal Anastomosis

As mentioned above, in the acute setting the connection between the posterior pericalossal branch of the
PCA and the distal pericalossal branch of the ACA is rather inadequate for meaningful reperfusion of
either vessel by the other. However, any slowly progressive constraint is another matter. The typical
scenario is Moya-Moya, where very proximal bilateral MCA and ACA constraint calls the PCA into
action. However, it need not be Moya-Moya any slowly evolving process will do.

In the following patient, a giant shenoid wing

meningioma resulted in occlusion of both
supraclinoid ICAs, similar to a Moya-Moya pattern.
Therefore, the primary method of reconstitution is
via leptomeningeal PCA-MCA (purple arrows) and
PCA-ACA (light blue arrows) collaterals, the
posterior to anterior pericalossal (yellow)
anastomosis, and left more than right middle
meningeal artery auto-synangioses with the MCA
territory on the left (motor strip, purple oval) and
right MMA to left ACA territory as well (white
arrows). Notice meningioma tumor blush (orange
oval)
Below are the cross-sectional images from the same patient:
Anterior Choroidal Artery Capture of Posterior
Inferior Temporal Territory
As mentioned above in the embryology section, the anterior choroidal artery occasionally retains part of
its embryonic inferior temporal cortical territory which normally belongs to the PCA. In this example,
the large anterior choroidal is yellow, and PCOM/PCA red:
Red=PCOM/PCA; Yellow=Anterior Choroidal Artery

Supply of the Cerebral Peduncle and Quadrigeminal Plate Collicular (Quadrigeminal) Artery
and Variants

The P2 segment of the PCA swings around the cerebral peduncle, underneath the thalamus, towards the
quadrigeminal plate, an further dorsal towards the occipital area. Branches of the PCA supply the
thalamus (inferior medial and lateral thalamus geniculate area), the peduncle, and the collicular plate.
There is wide variation in the description of this supply. Sometimes it is depicted as perforators arising
directly from the P2 segment, which makes sense geographically. For example, see diagram from none
less than Netter below:
 the
Others describe a stand-alone branch arising from P1 or proximal P2 segment,

Collicular (or Circumcollicular) artery and

courses just medial to the main P2 segment, around
the cerebral peduncle, towards the collicular plate
(hence the name). The artery (red) is beautifully
depicted in this specimen x-ray from the Yun Peng
Huang collection. Perforators to the peduncle
(pink) are also visualized:
Photo specimen, as above:
The picture is one of large P2 and slender collicular vessel just medial to it, often too small and too
superimposed on the PCA to be individually resolved on any modality. Its importance comes from the
territory it supplies the cerebral peduncle and quadrigeminal plate. Thus, damage to the artery can
lead to one instance of PCA-related hemiparesis, as seen in the image below with a developing infarct
in the cerebral peduncle:

At least on some occasions the Collicular artery can

be resolved, both with MRA and angiography.
Here is an example of one (red arrows), located
just medial to the P2 segment.
Here is an MRA of a different patient, with the same artery seen bilaterally. Could this be the
posteromedial choroidal artery instead? Certainly. Thats what Netter would say.
Here is an example of a focal hemorrhage in the quadrigeminal plate:
Angiography, performed because we didnt want to settle for a cavernoma, shows a shunt in the the
region of the quadrigeminal plate, with premature opacification of the Precentral Vein (purple)
Delayed angiography in frontal and lateral planes better displays the shunt following resolution of the
hematoma, now faintly shows some superior vermian veins (light blue), and the Collicular Artery (red).
Also note medial thalamic perforators originating as a single trunk, known as the artery of Percheron
(orange)
Superselective angiography with the microcatheter at the ostium of the Collicular artery (red)
demonstrates perfectly its course outlining the cerebral peduncle, with a small AVM (white) at the
collicular plate, draining via the Precentral Vein (purple) into the straight sinus (dark blue), and
retrogradely congesting paired superior cerebellar veins (light blue). Notice several slender perforators
to the peduncle (pink). The silly Percheron is orange. The top pair of frontal images is stereoscopic
3D-DSA angiographic views demonstrating the relationship of the Collicular artery (red) to the much
larger P2 segment of the PCA. Even in its AVM-related enlarged state, the Collicular artery remains
slender and difficult to differentiate from the P2 segment on nonselective vertebral angiography. No
wonder it is so often missing from descriptions. I hope that this case, and the image of the stroke, are
convincing enough.
I think that it is best to think of the Collicular artery as a perforator. For example, one sometimes finds
a common trunk for a number of lenticulostriate perforators from the MCA, though more often they
originate separately. It may be that the Collicular artery is an example of one such common trunk, while
at other times perforators to the peduncle could arise from the P2 segment (geniculate branches shown
in Netter for example are direct P2 perforators). Along the same lines, medial thalamic perforators
sometimes originate as a single trunk, with a totally out-of-proportion fame as the artery of Percheron,
or come off separately with the exact same effect and zero fanfare (white arrows)

Below is another example of the Percheron (white), a detail from one of the images shown above. The
hypoplastic left P1 is orange.
Posterior Lateral and Medial Choroidal Arteries

These important arteries supply the choroid plexus of the third and lateral (together with the anterior
choroidal) ventricles. A few simple and helpful observations:

the atrium of the lateral ventricle is located above the third ventricle. Therefore, the lateral choroidal
artery (red) will be situated above the medial choroidal (purple) on lateral views. Notice, in this case,
the relatively intense and persistent staining of the lateral ventricular choroid plexus (yellow), well into
the late venous phase. In isolation, it is of no clinical significance.
 the atrium of the lateral ventricle is located on roughly the same level as the occipital lobe, and much
more anterior. Therefore, a submental or Caldwell view will elevate the lateral choroidal artery (white,
image below) above the hemispheric branches of the PCA for a less obstructed view one of the key
uses of a Caldwell in the posterior fossa
Stereo Lateral below, again showing the lateral choroidal above the medial one; Red=posterior lateral
choroidal; Orange=posterior Medial choroidal (bilateral are seen on the left image) The lateral choroidal
has an inverted C-shape. The medial choroidal usually has a more S-shaped feature
Posterior choroidal arteries (lateral = red, medial =
yellow) with anastomosis near foramen of Monro
(purple), and associated thalamoperforating
branches (light blue). The orange arrow points to
the posterior pericalossal (a.k.a. splenial) branch
which was already shown above as a potential and
often inadequate anastomosis with the pericalossal
system of the ASA (white arrows)
Dominant posterior medial choroidal artery.

The balance between

All pericalossal arteries are in hemodynamic balance.

posterior medial and lateral choroidal arteries

can be shifted in either direction. The dominant
vessel traverses the foramen of Monro to supply the
choroid plexus of the correspondingly hypoplastic
feeder. In this example, the medial choroidal (red)
is dominant and extends superolaterally across the
foramen of Monro point (yellow) to supply the
lateral ventricular territory (orange). A
hypoplastic lateral choroidal artery (black) is
present. The splenial arteries are labeled in purple.

Below is an example of a dominant anterior choroidal artery (red), with its plexal point (purple) and
dominant choroidal (intraventricular) segment (yellow) curving superoanteriorly to outline the atrium
and lateral ventricular roof, territory normally supplied by the posterolateral choroidal, which is
hypoplastic in this case. Notice how the shape of the anterior choroidal here resembles that of the
posterolateral choroidal on lateral views
Red=A. Chor; Purple=plexal point; Yellow=choroidal segment

Posterior Lateral Choroidal Artery and

Thalamoperforating arteries supplying a left
thalamic AVM.
The anterior thalamus near foramen of Monro is usually supplied by an anteromedial perforator coming
off the posterior communicating artery, as is seen in this case. A ruptured AVM with a pseudoaneurysm
(green) arising from an anterior thalamic perforator (yellow) supplies the lesion together with the
posterior medial choroidal artery (dark blue) and posterior lateral choroidal artery (red). These arteries
and psedoaneurysm can be identified with high degree of certainty on a pre-angiographic post-contrast
MRI T1 gradient echo sequence (MP-RAGE in this case). The splenial artery is shown in light blue,
with retrograde opacification of the pericalossal artery attesting to major hydrocephalus

Variant supply of third ventricle choroid plexus and sequential identification

Having a series of images through which an arterial course and corresponding parenchymal and venous
phases can be traced is very useful when questions of identity arise. Here, variation in foramen of
Monro supply is present with distal origin of a branch coursing through velum interpositum (yellow) to
reach foramen of Monro, with a hypoplastic medial choroidal artery. The lateral choroidal system (red)
is well developed. Parenchymal and venous phases help identify the choroidal blush and venous
counterparts of the arterial vessels, increasing ones confidence in correctly identifying the anatomy.
Red=psterior lateral choroidal; yellow=fornix/choroidal branch in velum interpositum; purple=choroidal
blush of the lateral (higher) and third ventricle (lower and anterior to the lateral ventricular blush); light
and dark blue=internal cerebral vein
Anterior Choroidal Posterior Lateral Choroidal anastomosis the anterior choroidal beyond the
plexal point supplies the plexus of the temporal horn, where it is in balance with the posterolateral
choroidal going to the atrium region. This is elegantly shown in the following case of left choroidal
plexus AVM, supplied by both vessels with beautiful illustration of draining veins.
Red=anterior choroidal; yellow = posterolateral choroidal; pink=choroidal vein; light blue=inernal
cerebral vein; brown=basal vein to sylvian veins; dark blue = atrial vein; white = superior petrosal
sinus; green = midbasilar agenesis

Thats it for now. Will be updating as good cases come along. Hope the level of detail here makes up
for tardiness in creation of this page