Ally Ferber, MD
Resident Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
Esha Patel, DO
Resident Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
Steven Markos, MD
Attending Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
A 75 year old male with diabetes and hypertension presented for dizziness, headache, and vision changes. NIHSS 6. CT showed acute right occipital lobe infarct with occlusion of left PCA and multiple areas of severe stenosis. MRI brain showed acute posterior strokes of bilateral pontine, cerebellar, thalamic, and right occipital parietal lobe. Aspirin, plavix, and statin were started. Repeat MRI for worsening right sided weakness showed worsening brainstem stroke. Cilostazol was added. Prior strokes of bilateral thalamus suspected to be from the Artery of Percheron. The patient was discharged to an acute rehabilitation facility. AOP is a rare anatomic variant with significant clinical significance. Occlusion of the AOP may present with nonspecific variable symptoms and the inability to delineate the vessel on conventional angiography emphasizes the need to keep this differential in mind. Otherwise, patients may be diagnosed and treated ineffectively with potential devastating effects from recurrent strokes.
Discussions: Thalami blood supply is typically from branches of the ipsilateral PCA. A rare anatomic variant, called the Artery of Percheron (AOP), is significant in cases of posterior circulation ischemic strokes. AOP is a single trunk arising from one PCA supplying bilateral thalami. An occlusion of the AOP causes paramedian thalamic infarctions, documented as only 0.1-0.2% of cases of ischemic stroke. Clinical presentation can vary, including hypersomnolence, mental status changes, aphasia and dysarthria, amnesia, ocular and pupillary abnormalities. Visualization of the AOP is incredibly difficult with conventional angiography. The differential of lethargy or mental status changes should include occlusion of AOP to prevent a missed diagnosis and timely treatment of ischemic stroke. In the described patient with no documented history of stroke, the bilateral thalamic infarcts likely went undetected, thus untreated, resulting in additional ischemic infarcts requiring admission to acute rehabilitation.
Conclusions:
