Artery Of Percheron Research Articles

Percheron Artery Stroke and Reperfusive therapies: A systematic review and meta-analysis

Background and AimsPercheron Artery Stroke, affecting bilateral paramedian thalamic structures, accounts for 0.1–0.4 % of all acute ischemic strokes. Little is known about disability or mortality outcomes in patients receiving intravenous thrombolysis (IVT) or endovascular treatment (EVT), therefore a systematic review was carried out. MethodsA systematic search of Pubmed, Embase and Scopus databases for all kind of studies regarding Percheron Artery Stroke was performed. The review is registered in INPLASY (202410059). In total, 1895 papers were screened; 197 studies were included, consisting exclusively in case reports, retrospective series and conference abstracts. Data from 448 patients were analyzed in logistic regression. ResultsBoth IVT (ORIVT = 3.08; 95 % CI 1.4 – 6.7; p = 0.005) and EVT (OREVT = 5.77; 95 % CI 1.69 – 19.7; p = 0.005) were associated with reduced disability, as well as exclusive thalamic involvement (OR = 3.24; CI 2.1 – 5.1; p < 0.001) and higher Glasgow Coma Scale score (GCS) on admission (OR = 1.2; 95 % CI 1.12 – 1.28; p < 0.001). GCS (OR = 0.73, 95 % CI 0.63 – 0.82; p < 0.001) and exclusive thalamic involvement (OR = 0.36; 95 % CI 0.16 – 0.74; p = 0.005) were associated with lesser mortality, while IVT displayed a non-significant trend towards reduced mortality (ORIVT = 0.13; 95 % CI 0.01 – 1.04; p = 0.056). ConclusionThe present work, albeit summarizing data coming from low quality sources, suggests an association between both EVT/IVT and better outcomes in paramedian bilateral thalamic strokes.

Coma Due to Artery of Percheron Infarction: An Unusual Case Report

Ischemic stroke attributable to obstruction of the artery of Percheron (AOP), an infrequent anatomical arterial variant perfusing both medial thalami, can pose difficult diagnostic challenges. Obstruction or occlusion of the AOP results in bilateral paramedian thalamic infarction which is an unusual and rare vascular cause of coma. We present a 65-year-old male patient who came to the emergency department with altered sensorium for 10 days. The initial computed tomography (CT) brain was normal, followed by subsequent CT revealing an ill-defined hypodensity in the ventromedial aspect of the left thalamus and ventral aspect of the midbrain. T2/fluid-attenuated inversion recovery magnetic resonance imaging illustrated hyperintensity in the mesencephalon and bilateral paramedian thalami with restricted diffusion, suggesting an AOP infarct.

Artery of Percheron infarct – An ophthalmologist’s perspective

Thalamus is an important relay station in diencephalon which receives its blood supply mostly from the posterior cerebral artery. The Artery of Percheron (AOP) arises from the posterior cerebral artery and bifurcates to supply paramedian thalami. AOP infarction, though rare, presents with a triad of clinical features including altered mental status, memory impairment, and supranuclear vertical gaze palsy. Our patient had concurrent manifestation of vertical gaze palsy (both upward and downward) and third cranial nerve palsy in the left eye, which is an interesting clinical amalgamation. Our case report elucidates the quick recognition of the abnormalities in ocular motility through a simple, yet effective nine gaze ocular motility evaluation and thereby enhancing clinical recognition of this entity among the practicing general Ophthalmologists.

Percheron Artery Syndrome: A Case Report in Pediatrics

Percheron Artery Syndrome: A Case Report in Pediatrics

Successful Thrombolysis in Artery of Percheron Infarction: Grabbed an Extremely Rare Opportunity

Artery of Percheron (AOP) is an uncommon anatomical variation in the posterior circulation neurovasculature. It is a single artery arising from P1 segment of posterior cerebral artery (PCA) which supplies bilateral paramedian thalami and the rostral midbrain and as a result, occlusion of it leads to bilateral thalamic and mesencephalic infarction. Due to very low incidence (ranges from 0.1% to 2% of all ischemic strokes) and varied presentation, the diagnosis of AOP infarction requires strong clinical and radiological suspicion and hence, AOP infarction is often missed and patients are rarely thrombolysed. Here we discuss a patient with acute altered sensorium who recovered completely in short time following treatment with intra-venous thrombolysis for bilateral medial thalamic ischemic stroke due to AOP occlusion.

Isolated Hypersomnia Due to Bilateral Thalamic Infarcts: A Case Report

Thalamic pathology should be considered in patients with vague nonlateralizing neurological symptoms. Diagnosis of Percheron artery infarction is challenging and ofen made later in presentation due to lack of clinical awareness and the nonclassic stroke signs/symptoms on presentation. In this article, we report a case of bilateral thalamic stroke whose clinical presentation was dominated by a sudden onset of hypersomnia.

Thalamo-mesencephalic Branches of the Posterior Cerebral Artery: a 3D Rotational Angiography Study

PurposeThe thalamo-mesencephalic (TM) branches of the posterior cerebral artery (PCA) supply critical structures. Previous descriptions of these vessels are inconsistent and almost exclusively rely on cadaver studies. We aimed to provide a neuroradiological description of TM vessels in vivo based on routine 3D rotational angiographies (3D-RA).MethodsWe analyzed 3D-RAs of 58 patients with pathologies remote from the PCA. PCA-origins were considered. Delineation, origin and number of branches of the collicular artery (CA), the accessory CA (ACA), the posterior thalamoperforating artery (PTA), the thalamogeniculate artery (TGA), and the posterior medial (PMCA) and lateral (PCLA) choroid arteries were assessed. The PTAs were categorized based on Percheron’s suggested classification.ResultsA CA was identified in 84%, an ACA in 20%. The PTA was delineated in 100%. In 27%, PTA anatomy had features of several Percheron types (n = 7) or vessels emanating from a net like origin (n = 9). 26% had a type IIb PTA. A fetal type PCA origin with hypoplastic ipsilateral P1 was observed in 5 cases with type IIa (n = 2) or type IIb (n = 3) PTAs originating from contralateral P1. The TGA was identified in 85% of patients, with ≥ 2 branches in 67%. The PMCA was delineable in 41%, the PLCA in 100%.ConclusionThe prevalence of a proper “Artery of Percheron” type IIb PTA seems to be higher than previously reported. A fetal type P1-origin may be predictive of a type IIa/b PTA emanating from contralateral P1. 3D-RA may be useful for planning PCA interventions, as impairment of TM branches is a severe risk.

Artery Of Percheron Infarction: A Great Mimicker

The thalamus is a deep structure located in the diencephalon, whose arterial blood supply is mainly from four branches of posterior cerebral artery. The artery of percheron (AOP) is an infrequent variation of thalamic perfusion, occlusion of which presents with a heterogenous, atypical list of symptoms without focal signs. This is in contrast to the typical, easily recognizable focal neurology of other ischemic infarcts. Therefore, AOP infarctions may be misdiagnosed, delayed in diagnosis or missed altogether. It is a rare, but vital area of neurology that needs to be studied by clinicians to facilitate an overall care for patients.We report the case of a 59-year-old lady who presented to us with bilateral complete ptosis with bilateral vertical gaze palsy and nystagmus, whose initial NCCT brain was normal. Subsequent MRI showed bilateral thalamic and midbrain ischemic infarctions in the artery of Percheron distribution. Our case highlights the importance of high degree of suspicion, early diagnosis and role of MRI in the diagnosis when initial CT is normal.

Artery of Percheron Infarction: Clinical Presentation and Outcomes.

Occlusion of the artery of Percheron (AOP) produces bilateral thalamic infarction classically leading to deficits of arousal. This nonspecific presentation complicates the diagnosis of acute ischemic stroke. We sought to describe the spectrum of clinical presentation, diagnostic neuroimaging findings, and outcomes in AOP infarction (AOPi). We conducted a keyword search of our health system's neuroimaging database from 2014 to 2022 to identify patients with AOPi. We abstracted patient demographics, clinical presentation, neuroimaging findings, acute treatment, and modified Rankin Scale (mRS) scores (at baseline, 3 months, and 12 months). We used descriptive statistics to report our findings. Our initial keyword search identified 192 potential AOPi cases. Fifteen cases of AOPi were confirmed and included in our study (8 female [53%], median age 65 years [interquartile range (IQR): 59.5-79.5], median presenting NIHSS 6 [IQR: 2-22]). Common clinical findings on presentation were systolic blood pressure (SBP) > 140: 12 patients (80%); decreased level of consciousness (LOC): 11 patients (73%); diplopia: 8 patients (57%); disorientation: 6 patients (42%); dysarthria: 4 patients (28%); and acute memory/cognitive disturbance: 3 patients (21%). Twelve cases (80%) presented to the emergency department (ED). Median time from symptom onset to ED arrival was 774.5 minutes (IQR: 202.25-3789.0), 4 cases (27%) arrived within 4.5 hours, and one patient (7%) received intravenous thrombolysis. The median time from ED arrival to stroke diagnosis was 519.0 minutes (IQR: 227.5-1307). Head CT was only diagnostic when obtained >570 minutes from time last known well; MRI was diagnostic at all time points. Rates of functional independence (mRS ≤2) at baseline, 3 months, and 12 months were 64%, 21%, and 18%, respectively. The diagnosis of stroke was considerably delayed in patients with AOPi, and only one patient received IV thrombolysis. SBP >140, impaired consciousness, and diplopia were the most common findings at presentation. CT was often nondiagnostic, but MRI demonstrated bilateral thalamic infarct in all cases. AOPi caused considerable long-term morbidity. Clinicians should maintain a high degree of suspicion for AOP stroke and consider thrombolysis in appropriately selected patients.

An Update on the Superior Cerebellar Artery Origin Type.

Background and Objectives: The microanatomy of the superior cerebellar artery (SCA) is clinically significant. We, thus, aimed at patterning unilateral and bilateral possibilities of SCA origin. Materials and Methods: In total, 205 archived records of computed tomography and magnetic resonance angiograms were used. There were defined types of SCA origin from the basilar artery (BA): "0"-absent SCA, "1"-preterminal, "2"-collateral SCA, with SCA appearing as a terminal branch of BA, and "3"-SCA from the posterior cerebral artery (PCA) of the cerebral type. Fenestrations and duplications of SCA were recorded. Bilateral combinations of types were recorded as follows: A (1 + 0), B (1 + 1), C (1 + 2), D (1 + 3), E (1 + duplicated SCA), F (2 + 2), G (2 + 3), H (3 + 3), I (3 + duplicated SCA), J (1 + fenestrated SCA). Results: Type 0 SCAs were found in 0.25%, type 1 in 71.29%, type 2 in 19.06%, and type 3 in 9.41%. Absent and fenestrated SCAs were each found in a single case. The most frequent combinations were B (58.05%), C (13.17%) and F (13.17%). Bilateral symmetrical types occurred in 70.7% of cases. Fetal types of PCA and the artery of Percheron modified the BA ends. Combinations of C, F, and G changed the BA ends or tips; thus, different subtypes resulted in five BA bifurcation patterns, including five BA trifurcations and one BA quadrifurcation. BA trifurcation was also found in cases with duplicated SCAs. Conclusions: The SCA has various anatomical possibilities of origin and bilateral combinations that are not presented in anatomical lectures. Details on the specific end of the BA should be gathered on a case-by-case basis.

Impaired consciousness, a clinical manifestation of the Percheron artery syndrome: A case series

Impaired consciousness, a clinical manifestation of the Percheron artery syndrome: A case series

When a Hypersomnolent Hemodialyzed Patient Actually Has a Rare Stroke: A Case of Artery of Percheron Infarction With Paradoxical Embolism.

Artery of Percheron (AOP) is an uncommon anatomic variant of the arterial supply of the medial thalami. Owing to variable clinical presentation, challenging imaging diagnosis, and its rarity, it is difficult to diagnose AOP infarctions. We present a clinical case of a unique presentation of AOP infarction associated with paradoxical embolism and highlight the atypical clinical manifestations and challenging diagnosis of this stroke syndrome. A 58-year-old White female with chronic renal insufficiency on hemodialysis was admitted to our center with a 10-hour course of hypersomnolence and right-sided ataxia. She had normal body temperature, blood pressure, peripheral oxygen saturation, and heart rate and scored 11 points in the Glasgow Coma Scale and 12 points in National Institutes of Health Stroke Scale. Initial brain computerized tomography scan, electrocardiogram, and thoracic radiography were normal; transcranial Doppler ultrasound showed >50% stenosis at the P2 segment of the right posterior cerebral artery, and transthoracic echocardiogram, a patent foramen ovale and thrombus adherent to the hemodialysis catheter. On day 3, she underwent brain magnetic resonance that showed acute ischemic lesions at the paramedian thalami and the superior cerebral peduncles. AOP infarction due to a paradoxical embolism from a patent foramen ovale with a right atrial thrombus was the final diagnosis. AOP infarctions are a rare type of stroke with elusive clinical presentations and frequently, initial imaging assessment is normal. Early recognition is crucial, and a high index of suspicion is needed to suspect this diagnosis.

Basilar tip fenestration giving rise to Percheron's and mesencephalic arteries.

The basilar bifurcation region is a common site for intracranial aneurysms, as well as it gives rise to a group of perforating arteries that supply the mesencephalon and the thalamus. Complex vascular microanatomy poses a diagnostic and therapeutic challenge for neurosurgeons, neuroradiologists and neurologists. In this paper, we present a previously unreported case of basilar tip fenestration that gave rise to five perforating arteries: the artery of Percheron and four mesencephalic arteries. Due to invaluable clinical significance, the possibility of such a variant must be considered during performing various neurovascular procedures, since e.g., embolization of the fenestration misdiagnosed as an aneurysm would inevitably lead to severe neurological complications (consciousness disturbances, quadriplegia, and sensory loss). Comprehensive knowledge of the neuroanatomy and neuroembryology is crucial to safe execution of intracranial interventions.

Diffusion Restriction in Bilateral Thalami: Beyond Artery of Percheron Infarct.

Bilateral thalamic infarction, especially the medial thalamus, has been characteristically described in the artery of Percheron (AOP) affection. However, bilateral thalamic restriction has been described in many entities beyond the AOP infarction. Here we describe a case series (three cases) with infection as an etiology for bilateral thalamic lesions in the topographic distribution of the AOP from a tertiary care center in tropical India. : Case series during a 1-year period collecting cases with bilateral thalamic diffusion restriction on MRI who did not have thalamic infarcts and their outcomes. : Bilateral thalamic lesion can occur in both bacterial and viral infections such as tuberculosis, dengue, and SARS-COV-2. Thus, we intend to add infections as one of the etiologies in the ever-expanding list of conditions that produce bilateral thalamic restriction. All the acute symmetric thalamic lesions are not always secondary to vascular insult. Accurate assessment and prompt diagnosis can prevent unnecessary delays in treatment. To our knowledge, this is the first case series in the literature that throws light on the bilateral thalamic lesions in the topographic distribution of the AOP secondary to infections in a tropical country like India.

Somnolence Revealing Bilateral Thalamic Stroke in a Patient with Vertebral Artery Dissection

ABSTRACT Bilateral thalamic infarcts are rare presentations of stroke. They are the result of a complex combination of risk factors and a predisposing vessel distribution. The artery of Percheron, characterised by a single arterial trunk that irrigates both paramedian thalamic regions, can be occluded as a result of embolic diseases leading to bilateral paramedian thalamic infarcts. We describe a 35-year-old male patient with no relevant medical history who was admitted to hospital with somnolence lasting for 1 week. The scans revealed symmetric bilateral paramedian thalamic hypodensity consistent with bilateral thalamic stroke. Bilateral thalamic infarcts are unusual presentations of posterior circulation stroke; once they are diagnosed by an adequate neuroimaging protocol, further evaluation to define the cause is necessary.

0977 Bilateral thalamic strokes presenting as acute hypersomnia

Abstract Introduction Acute hypersomnia is a rare presentation of bilateral paramedian thalamic strokes (PTS). The typical symptoms of vertical gaze palsy, memory impairment, and even coma, do not include acute hypersomnia. Hypersomnia can be normal in appropriate settings. However, acute hypersomnia from a wake state is abnormal and should alert observers to a potential stroke, making timely intervention consequential to patient’s outcome. Report of case(s) A 59-year-old right-handed female, who was a passenger in a car, suddenly fell asleep and started snoring. Her sister, as the driver, was not able to arouse her. The patient was taken to the Emergency Department for further evaluation. Initial head CT was normal. Follow up MRI of the brain demonstrated bilateral PTS with extension to rostral midbrain (Axial images are available with DWI/ADC windows). Throughout her five-day-hospitalization, she remained somnolent without improvement. Her neurological exam was significant for decreased alertness, impaired short-term memory recall, vertical gaze palsy, and difficulty with two-step commands. She had no focal weakness or numbness. Electroencephalogram (EEG) showed generalized theta slowing background without seizure or epileptiform discharges. Cerebral and neck vessel images, cerebrospinal fluid studies, echocardiogram, and hypercoagulable tests were normal. Outpatient workup revealed atrial fibrillation, which was the strokes’ presumed etiology. She was also diagnosed with obstructive sleep apnea (Apnea-Hypopnea Index of 9.6) and was treated with CPAP. Despite compliance, her hypersomnia (Epworth Sleepiness Scale of 24) and cognitive dysfunction persisted, making a resumption of her prior employment not feasible. Bilateral PTS commonly stem from the artery of Percheron (AOP), which is a rare vascular variation where a single artery arises from the posterior cerebral artery to supply both thalami and midbrain.1 Ischemic disruption of the thalami’s dual role in sleep-wake regulation can lead to decreased daytime arousal and increased nighttime sleep disturbance with subsequent hypersomnia.2,3 Vertical gaze palsy is due to disruption of descending pathway of vertical gaze center. Conclusion Bilateral PTS have deleterious long-term clinical consequences. Increased recognition of acute hypersomnia as the presenting symptom for PTS can enhance acute stroke treatment with tPA and/or mechanical thrombectomy, and thereby improve the odds for recovery. Support (if any)

Embolization of midbrain arteriovenous malformation fed by the artery of Percheron in a child, the first case report and literature review.

Artery of Percheron (AOP) as main feeder artery of arteriovenous malformation (AVM) is extremely rare. Two cases of thalamic AVM fed by AOP have been reported to date and only one AVM been removed by microsurgery when attempt of intervention embolization failed. Midbrain AVM fed by AOP has not been reported yet. Here, we presented the first successful embolized case of midbrain AVM supplied by the AOP in a 10-year-old boy, who suffered dual oculomotor nerve palsy and secondary hemorrhage before embolization. During endovascular embolization, selective angiography by 1.2 Fr. Magic microcatheter showed an intranidal aneurysm located on the distal AOP. Two injections of a 1:4 ratio mixture of NBCA-MS completely occlude the nidus and intranidal aneurysm with no complications occurred. The child recovered well and the oculomotor deficits improved. This case highlighted that AOP is a clinically significant branch associated with AVM in midbrain and thalamus. Moreover, intervention embolization of midbrain AVM fed by AOP is a considerable therapeutic strategy.

Artery of Percheron Infarction: Clinical Presentation and Outcomes (P6-5.032)

<h3>Objective:</h3> We sought to characterize the presentation, acute treatment, and outcomes in patients with artery of Percheron (AOP) strokes. <h3>Background:</h3> The AOP is an uncommon vascular variant whose occlusion produces bilateral thalamic infarction often resulting in deficits of arousal. <h3>Design/Methods:</h3> We conducted a keyword search of our institution’s neuroimaging database from 2014–2022. All possible cases of AOP infarction were reviewed by two neurologists. We abstracted patient demographics, clinical presentation, acute treatment, acute neuroimaging findings, and laboratory results from the medical record. The median modified Ranking Scale (mRS) and interquartile range (IQR) at baseline, 3 months, and 12 months was analyzed to assess post-AOP stroke disability. Descriptive statistics were used to report clinical findings. <h3>Results:</h3> Our initial search identified 192 potential AOP cases. Fourteen cases of AOP infarction were confirmed and included in our study (8 female [57.1%], median age 67.5 [IQR 60.75–75], median presenting NIHSS 6 [IQR 2–15.25]). Hypertension or systolic blood pressure &gt; 140 (78.5%), decreased level of consciousness (6, 42.8%), and diplopia (6, 42.8%) were the most common presenting complaints. Eleven cases (78.6%) presented to the emergency department (ED). Median time from symptom onset to ED arrival was 14.3 hours (IQR 3.4–63.1); four cases (28.6%) arrived within the conventional thrombolysis time window. Median time from ED arrival to stroke diagnosis was 4.6 hours (IQR 3.8–15.8). Only one patient (7.1%) received IV thrombolysis. Median mRS increased from 2.0 (IQR 0–4) at baseline to 4.0 (IQR 3–5) at 3 months, and 4.0 (IQR 3–4.5) at 12 months. <h3>Conclusions:</h3> Apart from diplopia and hypertension, AOP infarction patients had diverse, non-specific clinical presentations resulting in delayed diagnosis. As a result, despite AOP infarction causing considerable long-term disability, only one patient received IV thrombolysis. Clinicians should maintain a high degree of suspicion for AOP stroke and intervene aggressively in appropriately selected patients. <b>Disclosure:</b> Dr. Ramezani Hashtjin has nothing to disclose. Dr. Ikramuddin has nothing to disclose. Dr. Streib has nothing to disclose.

Brain Infarction in the Artery of Percheron Supply Area due to Reversible Cerebral Vasoconstriction Syndrome

An ischemic stroke caused by the occlusion of the artery of Percheron encompasses both posterior thalami, and the resulting clinical presentation can mask the clinical presentation of a stroke. We present the case report of a 62-year-old female patient who was admitted to our emergency department in a soporous state after initial headache and dizziness. A neurological exam found left-sided spasticity and a flexor response to pain. Systemic thrombolysis was administered after an urgent computerized tomography (CT) of the brain with angiography. The interventional radiologist proposed a digital subtraction angiography which found a vasospasm in the right medial cerebral artery from the M2 seg- ment reaching distally, and a balloon dilation was done. Following the endovascular procedure, a CT scan showed ischemia in both posterior thalami. Additionally, the patient’s neurological impairment improved at that moment showing Parinaud syndrome, drowsiness, and left-sided palsy. The patient experienced a possible reversible cerebral vasoconstriction syndrome, the cause of which is still unknown, which resulted in an ischemic stroke. The typical clinical presentation of that syndrome was lacking, probably due to the presence of the artery of Percheron ipsilateral to the vasospasm. Our goal in presenting this case study is to draw attention to the artery of Percheron syndrome as a potential clinical sign of an acute ischemic stroke that can easily lead us to be misled.

Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis.

Occlusion of artery of Percheron (AOP), a rare variant of paramedian branches of posterior cerebral artery, results in a characteristic pattern of ischemic lesions in bilateral paramedian thalami with or without midbrain and anterior thalami involvement. To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. We retrospectively search in our stroke center database, patients with ischemic lesions in the AOP distribution. We collected clinical features and time between hospital admission and diagnosis. Imaging findings were categorized following a pre-selected classification. Of 2830 ischemic stroke admitted in our center, we identified 15 patients with AOP infarction (0.53%). Clinical manifestations were variable, but oculomotor disturbances, particularly vertical gaze palsy, were the most observed, followed by consciousness impairment, varying from drowsiness to coma. The most frequent imaging pattern was bilateral paramedian thalamic infarction with midbrain infarction, and the V-sign was recognized in 6 cases from this group. In 8 patients a fetal origin of the PCA was observed. The average time from first hospital admission to diagnosis was 28.09h. The prevalence of AOP infarction in our center was 0.53%. Diagnosis of AOP infarction can be challenging and should be suspected in case of sudden altered consciousness.