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Artery of Percheron Infarct_ Clinical and Radiological Manifestations


									Unusual Brain Lesion
 with a Usual Cause
Ryan Frederiksen MD, Sean Snodgress MD,
        Benjamin Kianmahd MSIV
        Department of Radiology
     Santa Barbara Cottage Hospital
       Clinical History: Patient A
n   36 year old right handed male with no prior
    medical history
n   Found unresponsive at gas station
n   No history of drug abuse, trauma,
    hypertension, hypercoaguable state or
    significant family history
n   Physical Exam: GCS 8
n   Labs: within normal limits except for BS > 500
Imaging: Patient A

 Initial Head CT Day 1:
 Imaging: Patient A

MRI DWI                    MRI ADC

          MRI Day 2:
  Bilateral thalamic infarcts.
Imaging: Patient A

    Head CTA Day 2:
Bilateral thalamic infarcts;
CTA portion was normal.
 Imaging: Patient A

      Head CT Day 3:
Hemorrhagic thalamic infarcts.
       Clinical History: Patient B
n   85 year old male with history of
    hypertension and GERD
n   Presented to PMD with 5 day history of
    ataxia and double vision
n   Physical Exam: leftward ataxic gait,
    bilateral horizontal nystagmus, no focal
    sensory or motor deficits
n   Labs: LDL 151
Imaging: Patient B

MRI DWI                         MRI FLAIR

      MRI Day 5 of Symptoms:
      Bilateral thalamic infarcts.
What’s the diagnosis?
        Bilateral Thalamic Infarcts

n   Broad differential diagnosis
    n Venous occlusion: vein of Galen, straight
      sinus, bilateral internal cerebral veins
    n Diffuse astrocytoma

    n ADEM

    n Arterial ischemia: artery of Percheron
         Discussion: Background

n   These two cases demonstrate an
    anatomic variant
n   Occlusion of the artery of Percheron
    results in a characteristic pattern of infarct
    n   Infarct of the bilateral paramedian thalamus
        with or without midbrain involvement
        Discussion: Background

n   The thalamus’ blood supply is usually
    supplied by:
    n multiple perforator vessesls originating from
      the posterior communicating artery
    n the P1 and P2 segments of the posterior
      cerebral arteries
          Discussion: Background
n   The anterior region is supplied by
    n   the polar (thalamotuberal) arteries, arising from the posterior
        communicating artery
n   The paramedian region is supplied by
    n   the paramedian (thalamoperforating) arteries which originate
        from the P1 segment of the posterior cerebral artery
n   The inferolateral region is supplied by
    n   the thalamogeniculate arteries which arise from the P2 segment
        of the posterior cerebral artery
n   The posterior region is supplied by
    n   the posterior choroidal arteries, which originate from the P2
        segment of the posterior cerebral artery.
       Discussion: Background

n   The paramedian arteries supplying the
    thalamus and midbrain exhibit the greatest
    amount of variability
n   According to Percheron, there are three
n   This exhibit focuses on a specific anatomic
    variant of the paramedian arteries, known
    as the Artery of Percheron
Discussion: Paramedian Thalamic Blood Supply

A. Many perforating arteries from the P1 segment of the PCA; the most

B. A single artery from the P1 segment; the artery of Perheron

C. An arcade of perforating arteries from both PCAs
Discussion: Artery of Percheron

A single dominant
artery supplying
the bilateral medial
thalami with
contribution to the
rostral midbrain

n   Common physical exam findings
    n Oculomotor palsy (76% of patients)
    n Mild gait ataxia (67%)

    n Deficits of attention (63%)

    n Fluency and error control (59%)

    n Learning and memory (67%)

    n Behavior (67%)
n   One retrospective study identified four
    patterns of artery of Percheron infarcts
    n   Bilateral paramedian thalamic with midbrain (43%)
    n   Bilateral paramedian thalamic without midbrain (38%)
    n   Bilateral paramedian thalamic with anterior thalamus
        and midbrain (14%)
    n   Bilateral paramedian thalamic with anterior thalamus
        without midbrain (5%)

The artery of Percheron is one of the few
examples where a cerebral blood vessel
 supplies structures on both sides of the
n   Lazzaro NA, et al. Artery of Percheron
    infarction: imaging patterns and clinical
    spectrum. AJNR Am J Neuroradiol. 2010
    Aug;31(7):1283-9. Epub 2010 Mar 18.
n   Matheus MG, et al. Imaging of acute bilateral
    paramedian thalamic and mesencephalic
    infarcts. AJNR Am J Neuroradiol. 2003 Nov-
n   Mujeeb, S, et al. Symmetric bilateral thalamic
    infarcts: a rare complication of cardiac
    catheterization. The Internet Journal of
    Cardiology. 2009 Vol 7; No 1.

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