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Bilateral thalamic infarction resulting from the occlusion of the artery of Percheron (AOP) is a rare cerebrovascular event with distinctive clinical presentations. This case report explores the intricate relationship between vascular anatomy, midbrain function, and clinical manifestations. A 48‐year‐old male farmer with a history of diabetes mellitus presented with sudden‐onset visual disturbances, diplopia, bilateral eyelid drooping, and loss of consciousness. Extensive evaluations, including advanced imaging techniques, led to the diagnosis of bilateral upper midbrain infarction involving AOP. This case underscores the complexity of neurovascular interactions, highlighting the importance of precise diagnosis, and tailored management in addressing rare cerebrovascular conditions. [ABSTRACT FROM AUTHOR]

Abstract Bilateral thalamic infarction resulting from the occlusion of the artery of Percheron (AOP) is a rare cerebrovascular event with distinctive clinical presentations. This case report explores the intricate relationship between vascular anatomy, midbrain function, and clinical manifestations. A 48‐year‐old male farmer with a history of diabetes mellitus presented with sudden‐onset visual disturbances, diplopia, bilateral eyelid drooping, and loss of consciousness. Extensive evaluations, including advanced imaging techniques, led to the diagnosis of bilateral upper midbrain infarction involving AOP. This case underscores the complexity of neurovascular interactions, highlighting the importance of precise diagnosis, and tailored management in addressing rare cerebrovascular conditions.

Purpose: 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. Aim: To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. Methods: 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. Results: 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 28.09 h. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Acute bilateral thalamic infarction is rare, and occlusion of the artery of percheron (AOP) may be one of its reasons. AOP occlusion results in an acute disturbance of consciousness, but mutism due to AOP occlusion is rare. We described a mutism patient with bilateral thalamic infarction presumably due to AOP occlusion. We also performed cerebral blood flow (CBF) evaluation by N-isopropyl-p-[123I]-iodoamphetamine single-photon emission computed tomography (123I-IMP-SPECT) as well as neural fiber evaluation by diffusion tensor tractography, discussing the mechanism of mutism. Case Description: A 92-year-old woman presented a gradual deterioration of consciousness. Diffusion-weighted images revealed high-intensity areas at the bilateral thalami, and we diagnosed AOP occlusion. We administered a recombinant tissue plasminogen activator. On day 14, her Glasgow Coma Scale score was 11 (E4V1M6), and she did not present any apparent paresis. She was mute but cognitively alert, although she could communicate by nodding or facial expression. 123I-IMP-SPECT showed CBF increase in the bilateral cerebellum and CBF decrease in the infarcted bilateral thalami and frontal lobes. Diffusion tensor tractography revealed the bilateral dentatothalamo-cortical tracts (DTCs). However, the tracts terminated at the parieto-occipital cortex, but not at the frontal cortex. She still had mutism on day 30. Conclusion: We reported the bilateral thalamic infarction patient presumably due to AOP occlusion, who presented mutism. The discontinuity of the bilateral DTCs resulted in her mutism, and our results supported the hypothesis that the cerebellum plays a significant role in uttering, associated with the bilateral DTCs. [ABSTRACT FROM AUTHOR]

Background: We present a unique case of a patient who suffered two rare events affecting the supranuclear control, first of the vertical and second of the horizontal eye movements. The first event involved bilateral thalamic infarcts that resulted in double depressor palsy. The second event occurred 1 year later and it involved supranuclear control of horizontal eye movements creating pursuit deficit. Case presentation: A 47-year-old male presented with complaints of diplopia upon awakening. He had atrial fibrillation, mitral valve regurgitation, aortic valve regurgitation, and a history of spleen infarction 1 year ago. His right eye was hypertrophic and right eye downgaze was limited unilaterally of equal degree in adduction and abduction. The patient was diagnosed with double depressor palsy of the right eye. Magnetic resonance imaging (MRI) of the brain showed an old infarction of the left thalamus, and diffusion MRI showed acute infarction of the right thalamus. The patient's daily warfarin dose was 2 mg and it was increased to 5 mg with cilostazol 75 mg twice a day. Seven weeks later, the patient's ocular movement revealed near normal muscle action, and subjectively, the patient was diplopia free. At follow-up 12 months later, the patient revisited the hospital because of sudden onset of blurred vision on right gaze. He was observed to have smooth pursuit deficit to the right side, and orthophoric position of the eyes in primary gaze. MRI of the brain showed an acute infarction in the right medial superior temporal area. Conclusions: The patient experienced very rare abnormal eyeball movements twice. This case highlights the importance of evaluating vertical movement of the eyes and vascular supplies when patients present with depressor deficit and supports the theory of a supranuclear function in patients who present with pursuit deficit. [ABSTRACT FROM AUTHOR]

This case highlights a patient presented with unusual symptoms, who was diagnosed on imaging with bilateral thalamic infarcts, probably due to an unusual anatomic variant. These paired lesions have a limited differential diagnosis that includes metabolic and toxic processes, infection, vascular lesions, and neoplasm. These differential diagnoses further narrowed with knowledge of the specific imaging characteristic of the lesions in combination with patient history. [ABSTRACT FROM AUTHOR]

Background: Simultaneous bilateral thalamic infarctions are rare and in most cases associated with typical clinical pattern which, beside other things, include neuropsychological changes. Case report: We report a case of a 37- year-old woman with acute onset ofdiplopia from skew deviation, right-sided central facial nerve palsy, left hemihypesthesia, ataxia, with normal level of consciousness and without any neuropsychological disturbances except minor memory deficit. She was diagnosed with bilateral thalamic infarction due to the cardioembolisation via patent foramen ovale. Conclusion: In cases of bilateral thalamic infarction one can presume the existence of rare anatomic variant of thalamic perfusion commonly known as the artery of Percheron, single artery trunk that branches to irrigate both paramedian territories of thalamus. The cause of infarction can be cardioembolism trough the patent foramen ovale, especially in young adults. Our case represents a combination of two specific pathological conditions - patent foramen ovale and bilateral thalamic infarction. Clinical presentation in this case was unusual for the bithalamic paramedian infarction. [ABSTRACT FROM AUTHOR]

Abstract: The thalami of the human brain obtain their blood supply from many perforating arteries, which exhibit complex distribution and many variations. One rare variation is the artery of Percheron that supplies the paramedian thalami bilaterally. This artery arises from the first segment of the posterior cerebral artery and gives rise to bilateral medial thalamic perforants. Occlusion of the artery of Percheron none rarely results in bilateral thalamic and mesencephalic infarctions. We describe the case of a 38-year-old male patient with a presumed occlusion of this artery in which MR imaging revealed characteristic symmetrical bilateral paramedian thalamic infarctions. The unique characteristics of this case are based on the young age of the patient, the absence of any risk factors or other diseases and even more on the rare clinical manifestations consisted of hypophonia, memory dysfunction, time disorientation and apathy. [Copyright &y& Elsevier]