Hospital: Hospital Universitario Marqués de Valdecilla.
Ciudad:
Nº:
Aut@r o Autores: P. Menéndez Fernández-Miranda, P. Sanz Bellón, A. Pérez Del Barrio, M. Drake Pérez, N. Valle San Román, E. Marco De Lucas.,
Presentación:
A 81-year-old patient was brought to the emergency department because of lightheadedness, blurred vision and muscular weakness at 10:30 a.m. She was initially diagnosed with presyncope and wait-and-see approach was decided. At 12:00 a.m. the patient started with a sudden onset abducens nerve palsy and a progressive diminution in consciousness so Code Stroke was rapidly activated and a multimodal CT was performed. The CT did not show any abnormalities. At 12:45 p.m. the patient went into a coma and the Neuroradiologist decided to perform a MRI. Diffusion Weighted MRI (DWI) revealed bilateral paramedian thalamic restricted diffusion areas confirmed in Apparent Diffusion Coefficient (ADC), and slightly hyperintensity in T2-FLAIR sequence, indicating acute infarction areas. Perfusion MRI and MR angiography were unremarkable.
Discusión:
We present a patient with bilateral paramedian thalamic acute infarcts, who concerning to the clinical picture and the image findings was diagnosed with Artery of Percheron (AOP) stroke. AOP refers to an anatomic variation in the brain vascularization in which a single arterial trunk (AOP) arises from the top of the basilar artery to supply both thalami, so an occlusion of this artery could lead to infarct both thalami at the same time. Cardioembolism and atherothrombosis entailed the most frequent etiologies. Clinical features include lightheadedness, impaired consciousness, cranial nerve palsies, and cortical signs such as aphasia. The index case represents a typical clinical presentation, with a severe mental state disturbance and a normal multimodal CT scan. In this kind of situation, it is mandatory to early discard AOP infarct and a MRI must be perform. If it is early diagnosed and treated, it has a favorable prognosis, otherwise the prognosis is ominous. The key MRI sequences are DWI, which shows restriction in the acute ischemic areas, and T2, used to demonstrate regions of established infarction.In the differential diagnoses of bilateral thalamic lesions, we should consider deep cerebral venous thrombosis, top of the basilar artery syndrome, Wernicke’s encephalopathy and metabolic and toxic conditions. These were discarded based on clinical picture and/or the lack of some other imaging findings mandatory for those other pathologies.
Conclusión:
We present a patient with bilateral paramedian thalamic acute infarcts, who concerning to the clinical picture and the image findings was diagnosed with Artery of Percheron (AOP) stroke. AOP refers to an anatomic variation in the brain vascularization in which a single arterial trunk (AOP) arises from the top of the basilar artery to supply both thalami, so an occlusion of this artery could lead to infarct both thalami at the same time. Cardioembolism and atherothrombosis entailed the most frequent etiologies. Clinical features include lightheadedness, impaired consciousness, cranial nerve palsies, and cortical signs such as aphasia. The index case represents a typical clinical presentation, with a severe mental state disturbance and a normal multimodal CT scan. In this kind of situation, it is mandatory to early discard AOP infarct and a MRI must be perform. If it is early diagnosed and treated, it has a favorable prognosis, otherwise the prognosis is ominous. The key MRI sequences are DWI, which shows restriction in the acute ischemic areas, and T2, used to demonstrate regions of established infarction.In the differential diagnoses of bilateral thalamic lesions, we should consider deep cerebral venous thrombosis, top of the basilar artery syndrome, Wernicke’s encephalopathy and metabolic and toxic conditions. These were discarded based on clinical picture and/or the lack of some other imaging findings mandatory for those other pathologies.
Bibliografía:
– Vinod KV, Kaaviya R, Arpita B. Artery of Percheron Infarction. Ann Neurosci. 2016, 23: 124–126. – Matheus MG, Castillo M. Imaging of acute bilateral paramedian thalamic and mesencephalic infarcts. AJNR Am J Neuroradiol. 2003, 24: 2005–2008. – Schmahmann