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substrate of the vascular amnesic (Korsakoff) syndrome; this simulates infarction of the hippocampi from occlusion of the medial temporal branch of the posterior cerebral artery as noted below Unilateral Cortical Syndromes Occlusion of branches to the temporal and occipital lobes gives rise to a homonymous hemianopia as a result of involvement of the primary visual receptive areas (calcarine or striate cortex) or of the converging geniculocalcarine bers It may be incomplete and then involves the upper quadrants of the visual elds more than the lower ones (see Chap 13) Macular or central vision may be spared because of collateralization of the occipital pole from distal branches of the middle (or anterior) cerebral arteries There may be visual hallucinations in the blind parts of the visual elds (Cogan) or metamorphopsia and palinopsia (Brust and Behrens) Posterior cortical infarcts of the dominant hemisphere cause alexia (with or without agraphia), anomia (amnesic aphasia), a variety of visual agnosias, and rarely some degree of impaired memory The anomias (dysnomias) are most severe for colors, but the naming of other visually presented material such as pictures, musical notes, mathematical symbols, and manipulable objects may also be impaired The patient may treat objects as familiar that is, describe their functions and use them correctly but be unable to name them Color dysnomia and amnesic aphasia are more often present in this syndrome than is alexia The defect in retentive memory is of varying severity and may or may not improve with the passage of time These syndromes are described in Chaps 22 and 23 A complete proximal arterial occlusion leads to a syndrome that combines cortical and anterior-proximal syndromes in part or totally The vascular lesion may be either an embolus or an atherosclerotic thrombus Bilateral Cortical Syndromes These occur as a result of successive infarctions or from a single embolic or thrombotic occlusion of the upper basilar artery, especially if the posterior communicating arteries are unusually small Bilateral lesions of the occipital lobes, if extensive, cause total cortical blindness, ie, a bilateral homonymous hemianopia, sometimes accompanied by unformed visual hallucinations The pupillary re exes are preserved, and the optic discs appear normal Sometimes the patient is unaware of being blind and may deny it even when it is pointed out to him (Anton syndrome) More frequently the lesions are incomplete, and a sector of the visual elds, usually on one side, remains intact When the intact remnant is small, vision may uctuate from moment to moment as the patient attempts to capture the image in the island of intact vision, in which case hysteria is incorrectly inferred The Balint syndrome (page 406) is another effect of bilateral occipitoparietal border-zone lesions In bilateral lesions con ned to the occipital poles, there may be a loss of central vision only (homonymous central scotomas) With more anteriorly placed lesions of the occipital pole, there may be homonymous paracentral scotomas, or the occipital poles may be spared, leaving the patient with only central vision Horizontal or altitudinal eld defects are usually due to similar restricted lesions affecting the upper or lower banks of the calcarine sulci With bilateral lesions that involve the inferomedial portions of the temporal lobes, the impairment of memory may be severe, causing the Korsakoff amnesic state In several of our patients, a solely left-sided infarction of the inferomedial temporal lobe impaired retentive memory These amnesic states and their accompaniments are fully described in Chaps 21 and 22 Bilateral mesiotemporal-occipital lesions also cause a lack of recognition of.

1 2 3 4 5 Figure 34-11 Regions of supply by the posterior segment of the circle of Willis, lateral view: (1) posterior cerebral artery; (2) superior cerebellar artery; (3) basilar artery and superior cerebellar artery; (4) posterior inferior cerebellar artery; (5) vertebral artery (posterior inferior cerebellar artery, anterior spinal artery, posterior spinal artery)

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An emergency repair differs from the Recovery Console process because it is an automated process To perform an emergency repair, start the computer using the Windows 2000 setup disks, elect to repair a failed installation, and choose the emergency repair process You will then be prompted to select Manual Repair or Fast Repair Fast Repair will automatically perform all repair options; Manual Repair will allow you to select which repair functions to perform The repair process includes checking the existence and integrity of boot files, such as NTLDR and BOOTINI and system files such as NTOSKRNLEXE If any of these files are missing or corrupt, they will be replaced by files on the installation CD The repair utility will also check the integrity of the boot sector and rebuild it if necessary

faces (prosopagnosia) These and other effects of temporal and occipital lesions are discussed in Chaps 13 and 22 Vertebral Artery The vertebral arteries are the chief arteries of the medulla; each supplies the lower three-fourths of the pyramid, the medial lemniscus, all or nearly all of the retro-olivary (lateral medullary) region, the restiform body, and the posteroinferior part of the cerebellar hemisphere (Figs 34-11 and 34-12) The relative sizes of the vertebral arteries vary considerably, and in approximately 10 percent of cases, one vessel is so small that the other is essentially the only artery of supply to the brainstem In the latter

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1 2 3 4 5 6 7 Figure 34-12 Regions supplied by the posterior segment of the circle of Willis, basal view: (1) posterior cerebral artery; (2) superior cerebellar artery; (3) paramedian branches of the basilar artery and spinal artery; (4) posterior inferior cerebellar artery; (5) vertebral artery; (6) anterior inferior cerebellar artery; (7) dorsal spinal artery (Reproduced by permission from Krayenbuhl and Yasargil)

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cases, if there is no collateral ow from the carotid system via the circle of Willis, occlusion of the one functional vertebral artery is equivalent to occlusion of the basilar artery (see below) The posteroinferior cerebellar artery (PICA) is usually a branch of the vertebral artery but can have a common origin with the anteroinferior cerebellar artery (AICA) from the basilar artery It is necessary to keep these anatomic variations in mind in considering the effects of vertebral artery occlusion The vertebral arteries are most often occluded by atherothrombosis in their intracranial portion Since the vertebral arteries have a long extracranial course and pass through the transverse processes of C6 to C1 vertebrae before entering the cranial cavity, one might expect them to be subject to trauma, spondylotic compression, and a variety of other vertebral diseases With the exception of arterial dissection, in our experience this happens only infrequently We have not seen convincing examples of spondylotic occlusion but several have been reported Extreme extension of the neck, as experienced by women who are having their hair washed in beauty salons, may give rise to transient symptoms in the territory of the vertebral artery Dissection of the vertebral artery is well described; it declares itself by cervico-occipital pain and de cits of brainstem function, usually bilateral It may be precipitated by vigorous and protracted bouts of coughing or by trauma to the neck or head Dissection of the extracranial vessels is discussed under Dissection of the Cervical and Intracranial Vessels, further on Examples of posterior circulation stroke in children have been reported in association with odontoid hypoplasia and other atlantoaxial dislocations, causing the vertebral arteries to be stretched or kinked in their course through the transverse processes of C1-C2 (see Phillips et al) The results of vertebral artery occlusion are quite variable When there are two good-sized arteries, occlusion of one PICA may cause no recognizable symptoms and signs If the occlusion of the vertebral artery is so situated as to block the branch supplying the lateral medulla and inferior cerebellum (PICA), a characteristic syndrome results with vertigo being a prominent symptom (see.

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