Bithalamic Infarction (Artery of Percheron Occlusion) after Anterior Cervical Discectomy and Fusion

Abstract

Bithalamic infarction resulting from occlusion of the artery of Percheron after cervical spine surgery is a rare pathological entity. Diagnosis and early detection are challenging. Prompt management may help to improve the outcome. We present a case of a 39-year-old male patient, smoker, diagnosed with multiple cervical disc herniations, who underwent Anterior Cervical Discectomy and Fusion (ACDF) for C3-C4, C4-C5, and C5-C6. During the 2-hour and 50-minute surgery, the patient was lying supine with his neck hyperextended. The intraoperative procedure was uneventful. During surgery, blood pressure ranged around 110 mmHg∖50 mmHg. At the end of surgery, the patient’s recovery from general anesthesia was normal with no delaying or complication; on next the day, patient developed a sudden loss of consciousness. Urgent brain computed tomography (CT) was normal; two days later, follow-up CT and CT Angiography (CTA) revealed bilateral thalamic infarction with right vertebral artery occlusion from its origin. Intraoperative surgical manipulation, hypotensive anesthesia, and prolonged neck hyperextension might have contributed to stroke in this patient. ACDF carries a potential risk for posterior circulation stroke. Artery of Percheron infarction should be considered in the differential diagnosis of patients developing a sudden loss of consciousness after ACDF. Vertebral artery thrombosis should be taken into account as an important possible cause of embolism.

Artery of Percheron Stroke as an Unusual Cause of Hypersomnia: A Case Series and a Short Literature Review

“…On May 27, 2020, a personal literature review based on a 2015-2020 PubMed search [key items: "artery of Percheron" AND ("case report" OR "case-series")] found 73 papers published in English language (30, 37, and 6 papers included females, males, and both sexes, respectively). Among the 37 studies including only males, 13 reported sleepiness or equivalent terms (i.e., hypersomnolence, drowsiness, or excessive daytime sleepiness) as a delayed complication of an AOP stroke (Table 1; Afana et al, 2019;Aryan et al, 2016;Bailey & Khadjooi, 2016;Goico & Mikesell, 2018;Harisuthan et al, 2018;Ince & Asan, 2018;Kamasak et al, 2015;Khanni et al, 2018;Oliveira et al, 2018;Shah & Ali, 2018;Vasconcellos et al, 2016;Zelante et al, 2015;Zhou et al, 2015).…”

Delayed massive cerebral infarction after perioperative period of anterior cervical discectomy and fusion: A case report

“…According to the search results of Google Scholar, only three case reports of acute cerebral infarction following cervical spine surgery have been published[ 3 - 5 ]. Afana et al [ 3 ] deemed that intraoperative surgical manipulation, hypotensive anesthesia, and prolonged neck hyperextension might contribute to their patients’ stroke.…”

“…According to the search results of Google Scholar, only three case reports of acute cerebral infarction following cervical spine surgery have been published[ 3 - 5 ]. Afana et al [ 3 ] deemed that intraoperative surgical manipulation, hypotensive anesthesia, and prolonged neck hyperextension might contribute to their patients’ stroke. Graffeo et al [ 5 ] expressed similar sentiments and speculated that the true incidence of cerebral ischemia might be underestimated by current reports, particularly in the delayed setting.…”

“…There are only three previous case reports on postoperative cerebral infarction related to cervical spine surgery. Two reports showed cases of stroke occurring immediately after surgery, and the remaining one reported the occurrence at postoperative day 3[ 3 - 5 ]. There has been no report about delayed cerebral infarction occurring after the whole perioperative period of an ACDF.…”

Epidemiology and Management of Iatrogenic Vertebral Artery Injury Associated With Cervical Spine Surgery

“… 32 49 54) Other factors, including instrumentation, probe maneuver for lateral exploration, cautery dissection, and prolonged neck hyperextension induce VAI. 2 34 58) Drilling was the most frequent cause of VAIs in previously reported cases. 20) Therefore, surgeons should be prudent when drilling the uncovertebral joint or neural foramen, and avoid coarse extensive lateral drilling.…”