Artery of Percheron infarction with persistent amnesia: a case report of bilateral paramedian thalamic syndrome

Abstract

Background The artery of Percheron is an uncommon anatomic variant which supplies the bilateral paramedian thalami and rostral midbrain. While infarction of its vascular territory can result in a wide range of symptoms, paramedian thalamic syndrome is classically described as a triad of symptoms including vertical gaze disturbances, fluctuating level of consciousness, and amnesia. There is minimal evidence to date to characterize the long-term cognitive consequences of infarction of the artery of Percheron utilizing neuropsychological assessment. Case presentation We describe a 40-year-old female patient initially presenting with dizziness, confusion and falls with unremarkable head CT scans. Subsequent MRI, more than 24 h after symptom onset, identified evidence of bilateral thalamic and rostral midbrain infarction. Neuropsychological testing was administered at 4 months post-stroke, with follow up testing at 1 year. The patient was found to have profound anterograde and retrograde amnesia, which did not change significantly over the first year of rehabilitation, and which was not easily identifiable in everyday encounters due to her relatively intact working memory and social skills. Conclusions As early diagnosis of infarction of the artery of Percheron is challenging, patients have frequently missed the time window for acute management of ischemic stroke. Moreover, this case study highlights the need for further research in deciphering the role of the paramedian thalamus in memory and cognition, as well as the importance of standardized neuropsychological testing for the artery of Percheron stroke patients to identify safety and rehabilitation concerns that may be overlooked.

Artery of Percheron infarction: A case report and literature review

“…AOP infarction is an important diagnostic consideration when presented with fluctuating consciousness, especially with a normal initial CT scan. MRI is currently the gold standard to demonstrate bilateral paramedian thalamic infarction [5] .…”

Acute percheron infarction: a precision learning

“…Acute AOP ischemia has great variability with respect to symmetry, size, and territory, which is mainly due to the thalamic arteries vary between individuals. These differences are related to the parent vessel from which each branch arises, the number and position of the arteries and their tributaries [ 9 , 12 , 18 ]. Paramedian bithalami of the 23 patients showed high signal intensity on FLAIR with restricted diffusion and hypointense in the ADC map (positive in 100%).…”

“…MRI, especially diffusion weighted imaging (DWI), plays an important role in the diagnosis of acute AOP infarction. At present, most neuroimaging literatures only describe the relationship between clinical manifestations and imaging [ 11 , 12 ]. However, in acute AOP infarction cases, whether imaging findings can suggest prognosis needs to be further confirmed.…”

Artery of Percheron Occlusion: A Diagnostic Challenge

“…The artery of Percheron is one of four anatomical variants of the paramedian artery, in which a single arterial trunk emerges from one of the posterior cerebral arteries to irrigate the paramedian region of the thalamus and the midbrain on both sides of the brain. These structures help regulate consciousness, sleep and awakening, and ischaemia in this region can manifest in various forms, such as changes in the state of consciousness or memory, psychosis, aphasia, dysarthria or oculomotor dysfunction [1][2][3] . This variant is estimated to occur in 33% [4] of the population and infarctions of this artery represent 4-18% of all thalamic infarcts and 0.1-2% [5] of all strokes.…”