Rare presentation of an isolated bilateral cerebral peduncular infarction

Abstract

Rationale: Due to the rarity of bilateral cerebral peduncular infarction (BCPI), its symptoms and prognosis are not clear. It is necessary to collect cases of pure cerebral peduncular infarction, explore the etiology and anatomy of midbrain infarction in depth, and develop meaningful tools for explaining clinical symptoms and predicting prognosis of patients.Patient concerns: We here provide a case of isolated BCPI with uncommon symptoms of ataxia, dysarthria, sensory disturbance, normal muscular strength, and full eye movements.Diagnoses: Diffusion weighted images and apparent diffusion coefficient map of our patient revealed acute and isolated bilateral peduncle cerebrum infarction.Interventions: Drugs that could improve circulation and antiplatelet were used in therapy.Outcomes: The infarct size was enlarged and new infarction was identified in the splenium of the corpus callosum and pons. The patient developed progressed disorder of consciousness and died at the eleventh day.Lessons: We inferred that the symptoms of ataxia, dysarthria, sensory disturbance, and mild paresis of the extremities could be prominent features of patients with pure cerebral peduncular infarction. We hypothesize that pure BCPI is also related to severe basilar artery stenosis or occlusion and there is no collateral circulation from PCA. This may explain the corresponding distribution of cerebral peduncular infarction and its poor prognosis. For these reasons, exploring etiology and anatomy of midbrain infarction in depth would have clinical value for predicting symptoms and prognosis. Abbreviations: ACA = arteriae cerebral artery, ADC = apparent diffusion coefficient, BA = basilar artery, BAD = branch atheromatous disease, BCPI = bilateral cerebral peduncular infarction, bil = bilateral, CPCT = corticoponto cerebellar tract, CST = corticospinal tract, DL = dyslipidemia, DM = diabetes mellitus, DWI = diffusion weighted images, fPCA = fetal posterior cerebral artery, HTN = hypertension, LAA = large-artery atherosclerosis, LIS = locked-in syndrome, lt = left, LVD = large vessel disease, MRA = magnetic resonance angiography, PCA = posterior cerebral artery, rt = right, UK = unknown, VA = vertebral artery.

Successful basilar artery dilatation in pure bilateral cerebral peduncular infarctions using balloon angioplasty

“…We consider that pure BCPI are rare, only occurring in the presence of a specific angioarchitecture; i.e., low hemodynamic perfusion around the BA tip. Fu X et al reported that pure BCPI are related to BA occlusion or severe stenosis and the absence of collateral circulation through the PCA [ 5 ]. The cerebral peduncle is supplied by perforating branches from the thalamoperforating artery, peduncular perforating artery, thalamogeniculate artery, and circumflex branches of the P1 or P2 segment of the PCA.…”

“…Two cases of pure BCPI without coexisting infarctions outside the midbrain have been reported previously [ 5 , 8 ]. In one of these cases, although antiplatelet drugs were administered, progressive occlusion of the vertebrobasilar artery caused the patient's symptoms to worsen, resulting in his death on the 11th day [ 5 ]. To the best of our knowledge, this is the first report of a case of pure BCPI in which balloon angioplasty produced a favorable outcome.…”

Acute Onset Quadriplegia and Stroke: Look at the Brainstem, Look at the Midline

“…A more complex and anecdotal vascular syndrome of the midbrain, which is associated with bilateral pyramidal tract damage, is the bilateral cerebral peduncular infarction (BCPI) [ 50 , 51 , 52 ]. Data from one medical center show that BCPI accounts for 0.26% of all of the admitted patients with an ischemic stroke [ 53 ], but the main limitation is that they were not pure midbrain infractions, and the other sites of infarction were found in the thalamus, pons and cerebellum.…”

“…Moreover, the case described by Asakawa et al [ 54 ] proposing the Mickey Mouse ears sign as a feature of this infarct the midbrain involvement was accompanied by a cerebellar infarction. Interestingly, two reported cases [ 50 , 51 ] had normal muscular strength. The most common symptoms of isolated BCPI included ataxia, dysarthria, sensory disturbance and mild paresis of the extremities, with a few disorders of eye movement or light reflex appearing upon a neurologic examination (rare involvement of the oculomotor nerve if the paramedian area is interested).…”

Isolated Bilateral Cerebral Peduncular Infarction Manifesting Pseudobulbar Palsy and Quadriparesis: a Case Report

“…According to previous study, BCPI has been reported to occur in 0.26% of all ischemic infarctions [ 2 ]. Isolated BCPI cases identified by magnetic resonance imaging (MRI) are extremely rare, and to the best of our knowledge, only a few cases have been reported previously [ 2 3 4 ]. It can be identified in MRI as a unique “Mickey Mouse ears” sign [ 5 ].…”