Artery of Percheron Infarction, a Rare Presentation; a Case Report

Abstract

Posterior fossa strokes, namely “Strokes in the territory of the posterior cerebral artery,” remain a challenging diagnosis. Its variable stuttering symptoms and non-focal manifestations result in a delay of its diagnosis and poor outcome. Artery of Percheron (AOP) is an anatomical vasculature variant arising from the P1 segment of a Posterior Cerebral Artery (PCA) as a single dominant thalamic perforating artery that supplies bilateral paramedian thalami and the rostral mesencephalon. Bilateral thalamic infarcts can present with altered mental status, hypersomnolence up to coma, aphasia, memory impairment, and vertical gaze palsy. Given the lack of classic stroke signs, the majority of AOP infarcts are not diagnosed in the emergency setting. Diagnosis is usually made following an MRI brain scan, which is usually obtained outside the therapeutic window for IV tissue plasminogen activator (tPA) administration. Timely vessel imaging is critical for diagnosis and initiation of treatment in those patients. This case highlights the rare presentation and diagnostic difficulty of a patient with an AOP infarction and reminds us to include thalamic pathology in patients presenting with nonspecific neurological symptoms and no obvious signs of stroke.