Bilateral Paramedian Thalamic Infarction Research Articles

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.

Agitation and somnolence by bilateral paramedian thalamic infarct

Key Clinical MessageBilateral thalamic infarction in paramedian artery territory may present with severe acute illness, confusion, coma and memory impairment. However, subtle clinical presentation as in our case should alert the clinician to consider such a diagnosis as it can be associated with good prognosis.AbstractBilateral thalamic infarct is a rare form of stroke. Mostly thalamic infarcts are unilateral. In most cases, bilateral thalamic infarction leads to cognitive dysfunction, opthalmoparesis, conscious impairment, behavioral disturbance, and corticospinal dysfunction. Here, we describe the case of a 75‐year‐old male patient who presented to the emergency department of our hospital with agitation and somnolence for one day. He had poorly controlled hypertension. There was no previous history of stroke, diabetes mellitus, hyperlipidemia, known cardiac disease, or smoking history. There was no seizure, recent headache, or visual disturbance. The patient was somnolent and not oriented to time, person, or place. Neurological examination did not show any focal weakness or vertical eye movement restrictions. Other systemic examinations, including those of the respiratory and cardiovascular systems, were unremarkable. Extensive laboratory investigations excluded potential metabolic, infectious, endocrine, or toxic etiologies. The patient did not have any recent history of drug misuse, including benzodiazepines. Brain MRI with diffusion‐weighted imaging showed an acute bilateral thalamic infarct. Cerebral angiography was unremarkable. The patient was treated with low molecular weight heparin 60 mg subcutaneously, aspirin 300 mg daily, and haloperidol 5 mg twice daily for agitation. After two weeks of intrahospital treatment, his condition improved (consciousness and orientation massively improved).

Clinical review and analysis of artery of Percheron infarction

Artery of Percheron infarction is a rare one of the neurovascular structure variants of acute ischemic stroke characterized by bilateral paramedian thalamic infarcts (BTPI), with or without mesencephalic infarction. Due to the low occurrence rate and various clinical manifestations, the early diagnosis of this disease is often missed. In addition, it is also difficult to diagnose this disease in an early implementation phase because cranial imaging and intracranial vascular imaging may show negative results. So far, its clinical cases have been rarely reported. We systematically reviewed the clinical manifestations, imaging characteristics, anatomical basis, and differentiation diagnosis of the artery of Percheron infarction and reported on three patients and their clinical and radiological medical imaging characteristic findings. We found that most of the infarct lesions in patients with an AOP infraction could not be displayed within a few hours or could not be fully displayed, even the embolism events, most of which showed typical imaging lesions at late review. The decrease of transient consciousness was obvious over the course of the three patients, and the decrease of active communication was also a major feature. Among the three cases, one patient had unilateral upper eyelid ptosis and miosis; the initial symptom of another patient was dizziness; and the other person had decreased computing power after infarction. These clinical symptoms are easily ignored in the diagnosis and treatment of patients with AOP infarction. Therefore, reporting the three clinical cases mentioned above will provide assistance for subsequent research by increasing clinical data.

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.

Recanalization of an occluded artery of Percheron causing acute bilateral thalamic infarction

An 87-year-old woman was admitted with acute onset of disturbed consciousness. On neurological examination, both pupils were dilated and non-reactive to light. Decerebrate rigidity was present. Babinski testing was positive. CTA suggested an isolated left P1 segment occlusion. The P2 segment was supplied from the left internal carotid artery via the posterior communicating artery. MRI showed bilateral paramedian thalamic infarctions. Because occlusion of the artery of Percheron was suspected, intravenous thrombolysis was performed. Digital subtraction angiography (DSA) revealed occlusion of the left P1 segment and spontaneous recanalization before endovascular treatment. Her consciousness improved immediately. When acute bilateral thalamic infarction suggests top of the basilar artery syndrome but no basilar artery occlusion is found, occlusion of the artery of Percheron should be considered. Thrombectomy of the affected P1 segment may be needed.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.

Acute percheron infarction: a precision learning

BackgroundSo far, the diagnosis of acute artery of percheron (AOP) infarction is uncommon. In this study, patients with acute AOP infarction were studied to explore the relationship of imaging findings, clinical manifestations and prognosis of acute AOP infarction.MaterialsA total of 23 patients with acute AOP infarction in our institution from 2014 to 2019 were reviewed retrospectively. All cases were evaluated by computed tomography (CT) and magnetic resonance imaging (MRI). The modified Rankin scale (MRS), blood examination, electrocardiogram and transthoracic echocardiography were used for detailed clinical and prognostic evaluation. All standard risk factors for these patients were recorded. The MRS scores were performed 90 days after discharge.ResultsFour different types of acute AOP infarction were identified: (a) bilateral paramedian thalamic infarction (BPTI, 52%); (b) bilateral paramedian thalamic with rostral midbrain infarction (BPTRMI, 30%), (c) bilateral paramedian and anterior thalamic infarction (BPATI, 13%), and (d) bilateral paramedian thalamic with red nuclei infarction (BPTRNI, 4%). These patients had consciousness disorder, memory dysfunctions, vertical gaze paresis and mesencephalothalamic syndrome. The 65% of patients with BPTI and BPATI experienced relatively good functional recovery and could carry out daily life activities (MRS score ≤ 2). However, patients with BPTRMI may have an unfavorable outcome.ConclusionsAlthough the clinical features are variable, DWI or ADC map can improve the diagnosis of acute AOP infarction patterns. Acute AOP occlusion requires immediate diagnosis and treatment to obtain more favorable outcome and avoid additional unnecessary procedures.

Percheron-like artery infarction after transsphenoidal surgery: illustrative case.

BACKGROUNDThe transsphenoidal approach to the skull base has enjoyed increasing popularity for surgery of the sellar region avoiding brain retraction and causing few severe complications. While vitally important vessels in this region show a high degree of variability, some anatomical variants might be involved in characteristic complications.OBSERVATIONSWe present the case of a 40-year-old female patient with acromegaly due to a pituitary adenoma that was transsphenoidally operated. Postoperatively, the patient presented with bilateral unresponsive mydriasis, loss of consciousness and tetraparesis. An MRI showed well-circumscribed bilateral paramedian thalamic infarctions which indicated a rare Percheron-like artery. At 2-year follow-up examination the patient was dramatically improved but with a profound impact on her ability to interact with the world.LESSONSThe basilar artery or perforators might be injured during dissection of suprasellar lesions. This vascular territory is essential to interaction of the brain with the outside world. We conclude that we will approach future suprasellar adenomas strictly intracapsularly.

Artery of Percheron Infarction: A Characteristic Pattern of Ischemia and Variable Clinical Presentation: A Literature Review.

The Artery of Percheron (AOP) is an uncommon anatomic variant that provides arterial supply to the paramedian region of the thalami and bilaterally to the rostral part of the midbrain; it is a solitary arterial trunk that branches from a proximal segment of the posterior cerebral artery (PCA). Although AOP infarction results in a characteristic pattern of ischemia-namely bilateral paramedian thalamic infarct with or without midbrain involvement-it may cause diagnostic difficulties due to the variety of its clinical presentations and wide differentials, as well as its small diameter and the difficulty of obtaining visualization through diagnostic imaging. Early neuroimaging of AOP infarction and correct diagnosis are mandatory for early initiation of the appropriate treatment and better patient outcomes. In this study, we discuss imaging the patterns of AOP infarction and its differentials and clinical presentation.

Acute bilateral paramedian thalamic infarct in the differential diagnosis of hyperactive delirium: A case report

Acute bilateral paramedian thalamic infarct in the differential diagnosis of hyperactive delirium: A case report

80 Sleeping Beauty

Abstract Background The artery of Percheron is a rare anatomic variant of arterial supply to the paramedian thalamus and rostral midbrain, and occlusion of the artery of Percheron results in bilateral paramedian thalamic infarcts with or without midbrain involvement. Early diagnosis of artery of Percheron infarction can be challenging because it is infrequent and early computed tomography or magnetic resonance imaging may be negative. Thus, it can be confused with other neurological conditions such as tumours and infections. Methods This is a retrospective case study of a gentleman admitted to a teaching Hospital in Limerick and diagnosed with an artery of Percheron infarction. Medical records and the neuro-radiological database were reviewed, and the diagnosis was made based on typical symptoms and radiological findings of artery of Percheron infarction. Results We report the case of a gentleman who was found unconscious in his car on the roadside during the daytime. He had a decreased GCS and upon arrival in the Emergency Department he was intubated and transferred to ITU The initial head computed tomography performed on admission was reported as unremarkable. Bilateral ischemia in the paramedian thalamic nuclei was documented on a follow-up computed tomography on day 24 after hospitalization. He was extubated after 24 hours. He made a full recovery and was discharged home on day 5. Conclusion Artery of Percheron infarcts are rare. The radiological diagnosis can initially often be judged as normal and in combination with variability in the neurological symptoms it is a rather difficult condition to diagnose.

Acute bilateral paramedian thalamic and mesencephalic infarcts due to occlusion of the Percheron artery: a case report

The thalamus and midbrain mesencephalon have a complex blood supply with a great number of feeding arteries. The blood build up of thalamus is being provided by four arteries originating from the vertebrobasilar system and posterior communicating artery. The paramedian thalamic artery is derived from the posterior cerebral artery proximal P1 segment. The infarcts of arterial constitute approximately 35% of all thalamic infarcts. However, bilateral infarctions of this region are very infrequent. Percheron artery originates from the first branch of the posterior cerebral artery and gives bilateral medial thalamic perforating branches. We described a patient of a 88-year-old woman with acute bilateral thalamic and midbrain infarcts due to occlusion of Percheron artery demonstrated on magnetic resonance imaging.

Transient coma as Percheron’s artery stroke

The artery of Percheron is a rare anatomic variation in the brain vascularization, in which a single arterial trunk arises from the posterior cerebral artery to supply both sides of brain structures, i.e., the thalamus and midbrain. Occlusion of this uncommon vessel results in a characteristic pattern of bilateral paramedian thalamic infarcts with or without mesencephalic infarctions. We report the case of a Caucasian woman who completely recovers after transient coma due to Percheron artery infarction.

Infarction of Percheron artery: A rare case report

The thalamus has strategic cores, which are divided into different functional classes and manage important cortical functions in harmony with each other. The mechanism proposed in the bilateral paramedian thalamic infarction is an occlusion of a single undifferentiated thalamo-perforating artery which is an anatomic variant. This artery, called the Percheron artery, appears from the first segment of the posterior cerebral artery and gives bilateral medial thalamic perforating branches. Bilateral paramedian thalamic infarction causes specific clinical signs and symptoms such as changes in consciousness ranging from letarj to coma, vertical gaze paralysis, ocular congestion loss and amnesia. In this case we aimed to present clinical and radiological features of a rare condition with infarction of percheron artery.

Clinically Complete Recovery after Bilateral Paramedian Thalamic Infarction

Clinically Complete Recovery after Bilateral Paramedian Thalamic Infarction

Erratum: Unusual Presentation of Childhood Reversible Angiopathy: Aphasia due to Acute Bilateral Paramedian Thalamic Infarct

Erratum: Unusual Presentation of Childhood Reversible Angiopathy: Aphasia due to Acute Bilateral Paramedian Thalamic Infarct

Unusual Presentation of Childhood Reversible Angiopathy: Aphasia due to Acute Bilateral Paramedian Thalamic Infarct

AbstractAn 8-year-old right-handed girl manifested aphasia after bilateral thalamic infarcts. The features of thalamic aphasia are similar to that of previously reported patients with thalamic lesions. Paucity of speech, reduced voice volume, some paraphasia, and severe dysgraphia were present, but comprehension and repetition were preserved. Thalamic aphasia is usually associated with left thalamic lesions. Our patient also had spatial neglect and anosognosia probably due to right thalamic infarction. She had recovered near-normal speech after rehabilitation.

Persistent anterograde amnesia due to the artery of Percheron occlusion: a case report

ABSTRACTBilateral thalamic infarction involving the artery of Percheron (AOP) can cause diagnostic difficulties due to the varying clinical presentations. AOP infarcts presented with isolated memory impairment are not common and the factors affecting the persistence of memory disorders are still unknown. A 41-year-old male patient was hospitalized with acute unconsciousness. MRI disclosed bilateral paramedian thalamic infarction The patient had isolated memory deficit and his anterograde amnesia continued without any change in the past decade. More cases might answer the questions concerning the intra- and extra-thalamic structures responsible for the amnesic syndrome and the factors affecting the persistence of the symptoms.

Status epilepticus as a presenting feature of bilateral paramedian thalamic and midbrain infarct—Artery of percheron infarct?

Abstract Seizures in stroke account for 11% cases of new onset seizure in adults. Risk factors for stroke associated seizures are cortical involvement, anterior hemisphere lesion, cardioembolic etiology. Seizure in case of thalamic or brainstem infarcts have rarely been described in literature and status epilepticus is very rare in these infarcts. Here we report a case of 40 years male patient who presented to emergency room with history of sudden onset vertigo and vomiting, followed by generalised tonic clonic seizures which evolved into status epilepticus. His magnetic resonance imaging of brain with diffusion weighted image (DWI) revealed acute infarct involving bilateral paramedian thalamic and midbrain region. Emergency physician should be aware of this atypical clinical scenario which can facilitate early diagnosis and treatment and thereby improve disease prognosis.

Assessment of Percheron infarction in images and clinical findings

ObjectiveTo assess the imaging and clinical features of patients with an artery of Percheron infarction comprehensively. MethodsOf 6539 patients with a first-ever stroke, 18 patients with a Percheron infarction were enrolled, and their images and clinical data were retrospectively investigated. ResultsAll patients underwent neurological intensive care unit (NICU) management. The initial symptom of a Percheron infarction included dizziness, transient blurred vision, double vision, barylalia, cerebellar ataxia, drowsiness, and a coma. Subsequent symptoms differed for the three subtypes of Percheron infarction, and the three subtypes are bilateral paramedian thalamic infarction with midbrain involvement, bilateral paramedian thalamic infarction without midbrain involvement, and bilateral paramedian and anterior thalamic infarction without midbrain involvement. Between favorable and unfavorable outcomes, there was no significant difference in the following patient characteristics including current smoking, hypertension, diabetes, hyperlipidemia, hyperhomocysteinemia, heart disease, time from stroke onset to medical care, and Glasgow Coma Scale score at admission (P>0.05), but there were significant differences in both the National Institute of Health stroke scale (NIHSS) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at admission (P<0.05). If the midbrain or larger infarct volume was involved or hemorrhagic transformation occurred, outcomes of a Percheron infarction were frequently unfavorable. ConclusionThe clinical presentation of patients with a Percheron infarction is variable; early recognition, image performance, NICU management, NIHSS, and APACHE II score would help in diagnosis, evaluation, and treatment.