Bilateral Paramedian Thalamic Infarct without Involvement of Corticospinal Tract

Abstract

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.