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(a and b) Thalamic vascular territories and their arterial supply (1) anterior vascular territory; (2) paramedian vascular territory; (3) inferolateral vascular territory; (4) posterior vascular territory; (5) posterior communicating artery; (6) P1 segment of the posterior cerebral artery (PCA); (7) P2 segment of the PCA; (8) polar (or thalamotuberal) arteries; (9) paramedian (or thalamoperforating) arteries; (10) thalamogeniculate arteries; (11) posterior choroidal arteries; (12) paramedian mesencephalic arteries b
Source publication
Strokes caused by normal variants of the cerebral circulation can be difficult to diagnose, hence a high index of suspicion is needed. This case series discusses the clinical and radiological aspects of one such stroke caused by occlusion of the artery of Percheron (AOP).
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Contexts in source publication
Context 1
... thalamus has a blood supply with contributions from both the anterior and posterior circulations [ Figure 1a]. Based on the blood supply, the thalamus can be divided into 4 vascular regions. ...
Context 2
... both the paramedian regions can get supplied by a single arterial trunk, the artery of Percheron (AOP). This artery arises from the P1 segment of one PCA and divides to supply bilateral paramedian thalami [ Figure 1b]. The paramedian mesencephalic arteries, which usually arise from the P1 segment to supply the superior medial parts of the midbrain, can originate from the AOP. ...
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Citations
... 9 The thalamic nuclei are complex and made up of five main functional units: reticular and intralaminar nuclei that involve consciousness state and nociception; sensory nuclei that connect sensory input to the cerebral cortex (medial geniculate nucleus (MGN; auditory), lateral geniculate nucleus (LGN; visual), and the ventrobasal complex); effector nuclei involving in language and motor processing; associative nuclei, which is crucial in advanced cognitive processes; and limbic nuclei that are involved in affective behaviors such as stress, anxiety, and agitation. 10 The paramedian thalamic artery, which arises from posterior cerebral and communicating arteries, is the ...
Key Clinical Message
Bilateral 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.
Abstract
Bilateral 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).
... The majority of thalamic infarctions are unilateral [9] . The thalamic nuclei are complex and made up of five main functional units: reticular and intralaminar nuclei that involve consciousness state and nociception; sensory nuclei that connect sensory input to the cerebral cortex ( medial geniculate nucleus (MGN; auditory), lateral geniculate nucleus (LGN; visual), and the ventrobasal complex); effector nuclei involving in language and motor processing; associative nuclei, which is crucial in advanced cognitive processes; and limbic nuclei that are involved in affective behaviors such as stress, anxiety, and agitation [10] . ...
Introduction and importance: Bilateral thalamic infarct is a rare form of stroke. Mostly thalamic infarcts are unilateral. Occlusion of the artery of Percheron leads to bilateral thalamic infarction with or without involvement of the midbrain. In most cases, bilateral thalamic infarction leads to cognitive dysfunction, opthalmoparesis, conscious impairment, behavioral disturbance, and corticospinal dysfunction.
Case Presentation: A 75-year-old male patient 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 MRI angiography was unremarkable. ECG and echocardiography did not show any potential cardioembolic source. The patient was treated with low molecular weight heparin 60 mg subcutaneously, aspirin 300 mg daily, and haloperidol 5mg twice daily. After two weeks of intrahospital treatment, his condition improved (consciousness and orientation massively improved). He was discharged for outpatient neurology clinic follow up.
Conclusion: Bilateral thalamic infarcts are rare presentations of posterior circulation stroke; conscious impairment, agitation, and cognitive dysfunction are the major presentations. Here we report an interesting case with hypertension diagnosed bilateral thalamic infarction without corticospinal tract involvement.
... To date, the etiology of AOP occlusion remains unknown, but most researchers believe that AOP infarction is caused by embolism or thrombosis; indeed, embolism, caused by cardiogenic, arthritogenic, and unknown etiologies, accounts for most cases of AOP infarction (16). Aaron et al. (24) and Perren et al. (18) found PFO to be involved in 1 of 4 and in 5 of 9 patients with cardioembolism, respectively. Therefore, in our patient, in whom AOP infarction with cardioembolism was highly suspected, TEE was critical to an early diagnosis (24). ...
... Aaron et al. (24) and Perren et al. (18) found PFO to be involved in 1 of 4 and in 5 of 9 patients with cardioembolism, respectively. Therefore, in our patient, in whom AOP infarction with cardioembolism was highly suspected, TEE was critical to an early diagnosis (24). In addition, recent studies have reported that quantitative susceptibility mapping of thrombi based on susceptibility-weighted imaging sequences can help discriminate between cardioembolism and other stroke subtypes (25), which may prove useful in determining the etiology of AOP infarction. ...
... The knowledge of the vascular supply of thalamic nuclei helps greatly to understand the so-called thalamic syndromes and localization of thalamic lesions. The thalamic arteries arise from the posterior communicating arteries and form perimensencephalic segment of the posterior cerebral artery [12][13][14][15] . This study demonstrates the clinical and vascular variation seen in thalamic infarcts and address the anatomic variations in our cohort. ...
... The artery of Percheron is a rare anatomic variant that provides a means by which a bilateral thalamic stroke can occur. It is a single branch from the posterior cerebral artery which supplies both sides of the thalamus and midbrain [1]. When infarcted, patients present with unique features such as excessive drowsiness and confusion [1]. ...
... It is a single branch from the posterior cerebral artery which supplies both sides of the thalamus and midbrain [1]. When infarcted, patients present with unique features such as excessive drowsiness and confusion [1]. Understanding its anatomy, the structures it supplies, and the presentation of a patient affected by a stroke in this area helps in identifying and understanding affected patients. ...
... The prevalence of the AOP in the general population is not clear, with estimates ranging from 11.7% of cadavers in one study [7], and up to 33% in another [8]. An AOP infarction represents 0.1-2% of all ischemic strokes [9] and carries a 12% mortality rate [1]. It can be indicated by a V-shaped hyperintensity in the midbrain on imaging, known as the "V sign," found in 67% of cases; this sign was not seen in this case [9]. ...
A 90-year-old male patient presented with excessive somnolence, right-sided weakness, and left facial droop. CT and MRI scans of the head, taken several days after initial head CT proved to be non-revealing, demonstrated a bilateral thalamic stroke, a rare phenomenon. The infarct arose in the territory of the artery of Percheron, an anatomic variant in which a single artery supplies both sides of the thalamus and midbrain. When this artery becomes occluded, it results in severely dysregulated consciousness and alertness. This type of stroke proved challenging for the medical team, due to poor resolution of initial imaging, as well as the therapy teams, due to the constant need for sleep. This case report outlines how barriers in diagnosis and management make knowledge of the artery of Percheron and its occlusion crucial to patient care and recovery.
... The clinical triad of altered sensorium, impaired cognition, and vertical gaze palsy is seen typically in AOP infarcts, as seen in our case. [3] Other less common presentations include hemiplegia, ataxia, and oculomotor disturbances. A stroke involving AOP needs to be considered in patients presenting with acute onset of altered sensorium, particularly fluctuating with lesions localizing to bilateral thalamus and/or midbrain. ...
... Clinical triad of fluctuating sensorium, impaired cognition, and vertical gaze palsy is seen typically in AOP infarcts, as seen in index case. [4] Less common presentations include hemiplegia, ataxia, and oculomotor disturbances (thalamopeduncular syndrome). Patients with basilar artery syndrome with occluded AOP can be considered for intra-arterial thrombolysis, but in our case time of onset of stroke was not clear, thus thrombolysis was avoided. ...
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A case report of artery of Percheron infarct.
... The artery of Percheron (AOP) is a rare anatomic variation in the posterior circulation of the brain in which a single arterial trunk arises from the first part of the posterior cerebral artery (PCA) and supplies the medial region of both thalami. The occlusion of the artery of Percheron results in bilateral infarctions in the middle aspects of thalami and brainstem [8,9]. We report a case of bithalamic infarction due to embolic occlusion of the artery of Percheron as a consequence of vertebral artery (VA) thrombosis. ...
... Stroke due to one vertebral artery occlusion has also been reported. Posterior circulation stroke and AOP occlusion are a serious complication with a higher risk of mortality and morbidity [6,9,11]. Yunoki et al., 2017, reported a case of right cerebellar infarction in a 50-year-old woman due to vertebral artery occlusion after ACDF [6]. ...
... In the case of AOP, an embolism is the most frequent cause of occlusion [9]. In our case, there was vertebral artery occlusion on Rt side thrombosis from the origin. ...
Bithalamic infarction resulting from occlusion of the artery of Percheron after cervical spine surgery is a rare pathological entity. Diagnosis and early detection are challenging. Prompt management may help to improve the outcome. We present a case of a 39-year-old male patient, smoker, diagnosed with multiple cervical disc herniations, who underwent Anterior Cervical Discectomy and Fusion (ACDF) for C3-C4, C4-C5, and C5-C6. During the 2-hour and 50-minute surgery, the patient was lying supine with his neck hyperextended. The intraoperative procedure was uneventful. During surgery, blood pressure ranged around 110 mmHg∖50 mmHg. At the end of surgery, the patient’s recovery from general anesthesia was normal with no delaying or complication; on next the day, patient developed a sudden loss of consciousness. Urgent brain computed tomography (CT) was normal; two days later, follow-up CT and CT Angiography (CTA) revealed bilateral thalamic infarction with right vertebral artery occlusion from its origin. Intraoperative surgical manipulation, hypotensive anesthesia, and prolonged neck hyperextension might have contributed to stroke in this patient. ACDF carries a potential risk for posterior circulation stroke. Artery of Percheron infarction should be considered in the differential diagnosis of patients developing a sudden loss of consciousness after ACDF. Vertebral artery thrombosis should be taken into account as an important possible cause of embolism.
... Of these, AOP is a single arterial trunk stemming off the P1 segment of one of the PCA and dividing to supply both thalami and the upper midbrain ( Figure 4). 2 AOP is a rare variant with Uz having noted only 1 AOP in 15 cadavers while Aaron et al observed AOP infarcts in 17 of 3589 patients with stroke (0.47%). 4,5 Various other series have reported the incidence of AOP infarcts to be 2% of all strokes to 4-18% of thalamic strokes. 6 In a large series of B/L thalamic infarcts by Lazarro et al, the commonest pattern of involvement was paramedian thalamic infarction with rostral midbrain infarct. ...
The artery of Percheron is a rare anatomic variant supplying the thalamus and the rostral midbrain. Infarct in this territory results in a wide array of neurological signs and symptoms causing diagnostic dilemma and management issues. We describe the clinical presentations in three cases admitted and evaluated for neurological symptoms and diagnosed as artery of percheron infarct after brain imaging. In one patient, the etiology turned out to be infective while the other two patients had cerebrovascular accident secondary to dilated cardiomyopathy and hyper homcystinimea respectively. Artery of percheron infarction is a rare entity and should be considered in patients with altered sensorium and behavioral manifestations with associated eye abnormalities. MRI brain is the investigation of choice to detect this rare variant of thalamic circulation.
... Mechanism for occlusion of artery of percheron includes atherothrombotic, cardioembolic, small vessel disease, vasculitis and rarely hypercoagulable state. Most common etiology for AOP infarction is cardio embolism followed by Cerebro-vascular small vessel disease [12]. In our case, we couldn't demonstrate any cardiac source of embolism and presumed etiology was cerebrovascular small vessel disease due to the vascular risk factors. ...
... Such patients are shown to show faster clinical recovery. 50% of patients have residual disability at the end of 6 months follow up [12]. Our case couldn't be subjected to thrombolytic therapy as he had active GI bleed and presented outside the window period. ...
