Artery of Percheron Infarction: A Short Review.

One uncommon type of ischemic stroke is occlusion of the artery of Percheron (AOP) leading to infarction of the paramedian thalami and mesencephalon. There are several variants of thalamic blood supply, and identifying the potential presence and infarction of an AOP is important in diagnosis and treatment of ischemic strokes affecting the thalami and mesencephalon, especially because of the unusual and variable presentation of these forms of ischemic strokes. This short review includes and discusses the case of a 58-year-old woman with an AOP infarct and indicates the importance of recognizing an AOP infarct early despite its clinical variations in order to treat the stroke in a timely fashion. This short review also includes a discussion of imaging modalities in such cases and clinical differential diagnoses to consider with management strategies.

A case of bilateral thalamic infarct complicating tuberculous meningoencephalitis.

Ischemic stroke can result from multiple etiologies. It can also be a complication of tuberculous meningoencephalitis and determine its outcome. stroke secondary to tuberculous meningoencephalitis, occurs in 30% cases in the basal ganglia region, unusually in the thalamus. The mechanism of stroke in this condition is vasculitis. We report an unusual case of bilateral thalamic infarcts complicating tuberculous meningoencephalitis. Ischemic stroke in tuberculous meningoencephalitis is unpredictable with poor prognosis despite antituberculous drug treatment, emphasising the importance of primary prevention, particularly in tuberculosis endemic areas.

[Acute global amnesia as an exclusive presenting symptom of thalamic infarct: a diagnostic challenge]. / Amnesia global aguda como forma exclusiva de presentacion de infarto talamico: un reto diagnostico.

INTRODUCTION: Isolated acute amnesia is an exceptional presenting symptom of thalamic stroke. This study analyses the clinical profile, the diagnosis, the treatment and the prognosis of these patients. CASE REPORTS: We conducted a retrospective review of the cases of thalamic infarct that presented exclusively as acute amnesia in our university tertiary hospital (n = 3) and a review of similar cases in PubMed (n = 20). 48% presented at least one risk factor of stroke (arterial hypertension, dyslipidaemia, diabetes mellitus, atrial fibrillation or a previous stroke). Amnesia was anterograde in three cases (13%) and global in the remaining 20 (87%). The infarct was detected in neuroimaging studies carried out within the first 24 hours in one patient (4%) and later in all the others; the average time until a diagnosis was established was 11 days. The initial CT scan was normal in five patients (22%). Eight cases (35%) required magnetic resonance imaging to detect the infarct. Of these, four subjects were studied directly with MR imaging. Amnesia clearly improved in eight patients (35%), and three of them (13%) made a full recovery. Fifteen patients (65%) presented mnemonic sequelae that interfered with their functional capacity. The clinical picture lasted less than 24 hours in two patients (9%). None of the cases received revasculisation therapy in the acute phase. CONCLUSION: The diagnosis of thalamic infarcts that begin exclusively with amnesia is very difficult and this has negative repercussions on their treatment in the acute phase. These infarcts can produce a functionally disabling memory deficit in a high percentage of patients.

TITLE: Amnesia global aguda como forma exclusiva de presentacion de infarto talamico: un reto diagnostico.Introduccion. La amnesia aguda aislada es una forma excepcional de presentacion del ictus talamico. Se analizan el perfil clinico, el diagnostico, el tratamiento y el pronostico de estos pacientes. Casos clinicos. Revision retrospectiva de los casos de infarto talamico que se presentaron exclusivamente como amnesia aguda en nuestro hospital terciario universitario (n = 3) y revision de casos similares en PubMed (n = 20). El 48% presentaba al menos un factor de riesgo de ictus (hipertension arterial, dislipidemia, diabetes mellitus, fibrilacion auricular o ictus previo). La amnesia fue anterograda en tres casos (13%) y global en los otros 20 (87%). El infarto se detecto en estudio de neuroimagen en las primeras 24 horas en un paciente (4%) y posteriormente en los demas, y la media de dias hasta el diagnostico fue de 11. La tomografia computarizada inicial fue normal en cinco (22%) pacientes. Precisaron estudio por resonancia magnetica ocho (35%) casos para detectar el infarto. De estos, cuatro sujetos se estudiaron directamente con resonancia magnetica. La amnesia presento una mejoria clara en ocho (35%) pacientes, y la recuperacion fue completa en tres (13%). Las secuelas mnesicas que interferian la capacidad funcional se presentaron en 15 pacientes (65%). La clinica persistio menos de 24 horas en dos pacientes (9%). Ningun caso recibio tratamiento revascularizador en fase aguda. Conclusion. Los infartos talamicos que comienzan de forma exclusiva con amnesia presentan notables dificultades diagnosticas que repercuten negativamente en su tratamiento en la fase aguda. Estos infartos pueden producir un deficit mnesico funcionalmente discapacitante en un porcentaje elevado de pacientes.

Rationale, design, and baseline participant characteristics in the MRI and cognitive substudy of the cardiovascular outcomes for people using anticoagulation strategies trial.

BACKGROUND: Covert vascular disease of the brain manifests as infarcts, white matter hyperintensities, and microbleeds on MRI. Their cumulative effect is often a decline in cognition, motor impairment, and psychiatric disorders. Preventive therapies for covert brain ischemia have not been established but represent a huge unmet clinical need. AIMS: The MRI substudy examines the effects of the antithrombotic regimens in COMPASS on incident covert brain infarcts (the primary outcome), white matter hyperintensities, and cognitive and functional status in a sample of consenting COMPASS participants without contraindications to MRI. METHODS: COMPASS is a randomized superiority trial testing rivaroxaban 2.5 mg bid plus acetylsalicylic acid 100 mg and rivaroxaban 5 mg bid against acetylsalicylic acid 100 mg per day for the combined endpoint of MI, stroke, and cardiovascular death in individuals with stable coronary artery disease or peripheral artery disease. T1-weighted, T2-weighted, T2*-weighted, and FLAIR images were obtained close to randomization and near the termination of assigned antithrombotic therapy; biomarker and genetic samples at randomization and one month, and cognitive and functional assessment at randomization, after two years and at the end of study. RESULTS: Between March 2013 and May 2016, 1905 participants were recruited from 86 centers in 16 countries. Of these participants, 1760 underwent baseline MRI scans that were deemed technically adequate for interpretation. The mean age at entry of participants with interpretable MRI was 71 years and 23.5% were women. Coronary artery disease was present in 90.4% and 28.1% had peripheral artery disease. Brain infarcts were present in 34.8%, 29.3% had cerebral microbleeds, and 93.0% had white matter hyperintensities. The median Montreal Cognitive Assessment score was 26 (interquartile range 23-28). CONCLUSIONS: The COMPASS MRI substudy will examine the effect of the antithrombotic interventions on MRI-determined covert brain infarcts and cognition. Demonstration of a therapeutic effect of the antithrombotic regimens on brain infarcts would have implications for prevention of cognitive decline and provide insight into the pathogenesis of vascular cognitive decline.

A Regional Network Organization for Thrombectomy for Acute Ischemic Stroke in the Anterior Circulation; Timing, Safety, and Effectiveness.

BACKGROUND: Mechanical thrombectomy (MT) in association with intravenous thrombolysis is recommended for treatment of acute ischemic stroke (AIS), with large vessel occlusion (LVO) in the anterior circulation. Because MT is only available in comprehensive stroke centers (CSC), the challenge of stroke organization is to ensure equitable access to the fastest endovascular suite. Our aim was to evaluate the feasibility, efficacy, and safety of MT in patients initially managed in 1 CSC (mothership), compared with patients first managed in primary stroke center (PSC), and then transferred to the CSC for MT (drip-and-ship). METHODS: We retrospectively analyzed 179 consecutive patients (93 in the mothership group and 86 in the drip-and-ship group), with AIS secondary to LVO in the anterior cerebral circulation and a clinical-radiological mismatch (NIHSS ≥ 8 and DWI-ASPECT score ≥5), up to 6 hours after symptoms onset. We evaluated 3-month functional modified Rankin scale (mRS), periprocedural time management, mortality, and symptomatic intracranial haemorrhage (sICH). RESULTS: Despite significant longer process time in the drip-and-ship group, mRS ≤ 2 at 3 months (39.8% versus 44.1%, P = .562), Thrombolysis in cerebral infarction 2b-3 (85% versus 78%, P = .256), and sICH (7.0% versus 9.7%, P = .515) were similar in both group regardless of baseline clinical or radiological characteristics. After multivariate logistic regression, the predictive factors for favorable outcome were age (odds ratio [OR] -5years= 1.32, P < .001), initial NIHSS (OR -5points = 1.59, P = .010), absence of diabetes (OR = 3.35, P = .075), and the delay magnetic resonance imagining-puncture (OR -30min = 1.16, P = .048). CONCLUSIONS: Our study showed encouraging results from a regional protocol of MT comparing patients transferred from PSC or brought directly in CSC.

Ipsilateral Ptosis and Contralateral Ataxic Hemiparesis as Initial Symptoms of Combined Tuberothalamic and Paramedian Artery Infarction.

Thalamic infarcts, accounting for approximately 14% of lacunar infarcts, exhibit varied clinical manifestations due to complex anatomy of nuclei and varying blood supply. Pure and combined types of thalamic infarctions have been summarized in some paper, but information of cerebral angiography was not mentioned. Here we report a rare case of combined tuberothalamic and paramedian artery occlusion presenting with ipsilateral ptosis and contralateral ataxic hemiparesis.

Intraoperative neurophysiologic monitoring (IONM) changes associated with a case of delayed thalamic infarct: Implications for postoperative management.

Treatment of cerebral aneurysms poses a risk of cerebral hemorrhage and/or ischemia; these potential sequelae are usually associated with changes in intraoperative neurophysiologic monitoring (IONM) modalities. Our case demonstrates a patient with significant changes in IONM during the treatment of a right posterior cerebral artery aneurysm who did not develop neurologic deficits until three days postoperatively. IONM changes can represent a guide in postoperative patient management and may pose grounds for closer monitoring of patients with IONM changes that do not develop immediate postoperative deficits.

Hyperbaric oxygen promotes neural stem cell proliferation by activating vascular endothelial growth factor/extracellular signal-regulated kinase signaling after traumatic brain injury.

Hyperbaric oxygen (HBO) therapy and neural stem cell (NSC) transplantation can improve traumatic brain injury (TBI) clinically. This study aimed to investigate the mechanism of HBO promoting NSC proliferation and neurological recovery after TBI. Twenty-four Sprague-Dawley rats were divided randomly into three groups: a sham group, a TBI group (constructed using Feeney's free-fall method), and an HBO-treated TBI group. Neurological function was evaluated by Neurological Severity Scores on days 1, 3, and 7, and we found that TBI-induced poor neurological function was improved by HBO. On day 7 after TBI, we observed that TBI promoted NSC proliferation, migration to the lesion area, and the levels of vascular endothelial growth factor (VEGF), VEGFR2, Raf-1, MEK1/2, and phospho-extracellular signal-regulated kinase (ERK) 1/2 protein, which were further boosted by HBO, from immunohistochemistry, immunofluorescence, and Western blot experiments. In vitro, cell injury was applied to NSCs isolated from neonatal Sprague-Dawley rats by the Cell Injury Controller II system. Moreover, data from the BrdU Kit and Western blot showed that in-vitro HBO significantly accelerated NSC proliferation and the levels of proteins related to cell cycle and the VEGF/ERK pathway after cell injury, which was suppressed by the VEGFR2 inhibitor. Taken together, this study indicated that HBO may promote NSC proliferation by activating VEGF/ERK signaling and play a crucial role in neuroprotection after TBI.

Bilateral Paramedian Thalamic Infarction.

INTRODUCTION: Rarely, both paramedian thalami receive arterial blood flow from a single unilateral vessel arising from the first segment of 1 posterior cerebral artery. This artery has received the name of artery of Percheron (AP). There is no consensus regarding the true prevalence of this anatomical variant. Bilateral paramedian thalamic infarcts are uncommon (0.1% to 2% of ischemic strokes). The main cause is the occlusion of the AP due to cardioembolism. Diffusion-weighted magnetic resonance imaging demonstrates the lesion in the acute setting. MATERIALS AND METHODS: From September 2004 to October 2011, we identified 5 patients who had bilateral paramedian thalamic infarcts. We describe clinical findings and diagnostic imaging patterns observed in these cases and review the literature. RESULTS: Three men and 2 women with bilateral paramedian thalamic infarction probably due to occlusion of AP are described. Mean age at presentation was 58±24 years. Magnetic resonance imaging showed the lesion in all patients. Four patients presented loss of consciousness as initial symptom. Only 1 patient evidenced mesencephalic extension of the infarct on magnetic resonance imaging, although 4 presented abnormal ocular signs. No patients received intravenous thrombolisis because of delayed diagnosis. All patients were discharged home. A 90-year-old woman recovered completely and the other 4 subjects persisted with cognitive symptoms and gaze abnormalities. CONCLUSIONS: Clinical presentation and imaging patterns described in this group of patients were similar to published data. High level of suspicion based on clinical and imaging findings is essential for early diagnosis of this rare condition. None of our patients had an early diagnosis of acute ischemic stroke and received proper thrombolytic treatment.

Decreased consciousness: bilateral thalamic infarction and its relation to the artery of Percheron.

This case series highlights two patients seen in the same stroke centre presenting with unusual symptoms. They were later diagnosed with bilateral thalamic infarcts, probably related to an unusual anatomical variant. The difficulties in establishing the diagnoses due to their relative rarity and complexity could have impacted on patient outcomes.

Relationship between Chinese medicine pattern types, clinical severity, and prognosis in patients with acute cerebral infarct.

We investigated the relationship between Chinese medicine pattern (CMP) types, their severity, and prognosis in patients (n = 187) with acute cerebral infarct (ACI). Six CMPs (wind, phlegm, fire-heat, blood stasis, qi deficiency, and yin deficiency and yang hyperactivity) were evaluated according to inspection, listening and smelling, inquiry, and palpitation. The severity and prognosis of each pattern type was determined according to the Glasgow Coma Scale (GCS), Modified Rankin Scale (MRS), National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), and Functional Independence Measure (FIM), recorded at stroke onset and 12 weeks after stroke onset. The phlegm pattern (PP) patients displayed lower GCS, BI, and FIM scales scores, and higher MRS and NIHSS scales scores, than the nonphlegm pattern (N-PP) patients at, and 12 weeks after stroke onset, suggesting the clinical severity is greater and the prognosis is worse in PP patients with ACI than in non-PP patients with ACI.

Bilateral thalamic infarct as a diagnosed conversion disorder.

Bilateral thalamic infarcts are an uncommon type of cerebral infarct. Bilateral paramedian thalamic infarctions may lead to a severe impairment of consciousness. The sudden onset of a lethargy or comatose state, in the absence of motor deficits, easily evokes the idea of a subarachnoid hemorrhage. Other patients present with behavior changes, disorientation in space and time, memory loss, or thought disorders. We believe that bilateral thalamic infarction is often missed in emergency department (ED) in relatively young patients, especially when magnetic resonance imaging is not performed. In these cases, the patient can be discharged with various psychiatric diagnoses. We suggest that bilateral thalamic infarct should be considered in patients in the ED with new diagnoses of conversion disorder.

Bilateral thalamic infarcts due to occlusion of the Artery of Percheron and discussion of the differential diagnosis of bilateral thalamic lesions.

The Artery of Percheron is a rare vascular variant in which a single dominant thalamoperforating artery arises from one P1 segment and bifurcates to supply both paramedian thalami. Occlusion of this uncommon vessel results in a characteristic pattern of bilateral paramedian thalamic infarcts with or without mesencephalic infarctions. We report a case of a 31-year-old man with acute bilateral thalamic infarcts and a truncated Artery of Percheron demonstrated on magnetic resonance angiography (MRA). Occlusion of the vessel was presumably due to embolism from a patent foramen ovale that was subsequently closed. The case presentation is followed by a discussion of bilateral paramedian thalamic infarcts including the causes and clinical presentation. The differential diagnosis of vascular and nonvascular etiologies of bilateral thalamic lesions is also discussed.

Thalamic and midbrain infarct during transarterial chemoembolization of hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is a well accepted and a relatively safe procedure, however certain rare and serious complications may occur during or after the procedure with profound morbidity and mortality. Only a few cases have been reported describing cerebral embolization during the procedure. We are reporting a case in which cerebral lipiodal embolization occurred in the second session of TACE, during the procedure and without any evidence of pulmonary embolism causing midbrain and thalamic infarct. The possible explanation could be an aberrant connection between the hepatic and pulmonary vessels which might have developed due to the involvement of the diaphragm, pleura and pulmonary vessels after the first session of TACE.