Bilateral thalamic infarction, unforgettable after reading

*For medical professionals to read for reference only, bilateral thalamic infarction is relatively rare in clinical practice.
The clinical symptoms can show a typical triad, and the imaging features are symmetrical ventromedial infarction.
Most of them have a poor prognosis
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Most doctors may be deeply impressed when they encounter it in clinical practice, and they will never forget it
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In this paper, a case of bilateral thalamic infarction encountered in clinical work is used to systematically review the disease
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First look at the case data The patient is a 58-year-old male
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▌ Chief complaint: unconsciousness, weakness of limbs for 8 hours
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▌ History of present illness: 8 hours before admission, the patient had unconsciousness without obvious incentive, limb weakness, unable to hold objects, unable to walk independently, and lack of fluency in speech
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No slanted mouth, no headache, nausea, vomiting, no unresponsiveness, no unresponsiveness, no gibberish, no dysphagia, no coughing when drinking, no convulsions, no incontinence, no fall trauma
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Due to the gradual aggravation of symptoms, there was no cerebral hemorrhage in the emergency CT of our hospital, and the initial diagnosis was "cerebral infarction", and he was admitted to the hospital
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History of long-term drinking
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Denied other important medical history
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▌ Physical examination on admission: T 35.
6℃, P 110 times/min, R 17 times/min, BP 134/99mmHg
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Light coma, bilateral unequal pupils, left pupil diameter 4mm, right pupil diameter 2mm, bilateral light reflexes are sluggish, eye movements are uncooperative, the right nasolabial fold is shallow, the tongue is centered, the gag reflex is normal, Soft neck
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Muscle strength examination showed uncooperative, normal muscle tone of the limbs, normal bilateral tendon reflexes, positive Pap's sign on the right side, and negative Pap's sign on the left side
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The heart rate was 110 beats/min, the rhythm was uniform, and no obvious murmur was heard in the auscultation area of ​​each valve
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The breath sounds of both lungs were coarse, and no obvious dry or wet rales were heard
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No obvious edema was found in both lower extremities
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Head MRI after admission showed: 1.
Midbrain and bilateral thalamic infarction; 2.
Multiple ischemic foci and softening foci of bilateral cerebral parenchyma; 3.
MRA showed bilateral posterior cerebral arteriosclerosis-like manifestations
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(Fig.
1.
Cranial MRI showed midbrain and bilateral thalamic infarction) (Fig.
2.
Cranial MRA showed bilateral posterior cerebral atherosclerosis) After admission, aspirin and clopidogrel bisulfate were given to antiplatelet aggregation, atorvastatin calcium Anti-atherosclerosis, butylphthalide to improve collateral circulation, Shuxuening to improve microcirculation and other drug treatments
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After 14 days of treatment, the patient's condition improved slightly.
Physical examination showed drowsiness, slightly slurred speech, and slightly slow response
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The pupils are equal in size and round, with a diameter of 3mm.
The light response is sensitive.
The left eye is adduced incompletely, and the eyes cannot move up and down
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The muscle strength of the limbs was grade 5, and the Pap's sign of both lower extremities was positive
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The breath sounds of both lungs were coarse, and no obvious dry or wet rales were heard
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No obvious edema was found in both lower extremities
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(Figure 3.
Schematic diagram of the thalamic supplying artery, the picture is from the Internet) Detailed explanation: Percheron artery infarction The blood supply of the thalamus is mainly supplied by four arteries, namely the thalamic tubercle artery, the traditional thalamic artery (paramedian artery), and the thalamic geniculate artery.
and the retrochoroidal artery (Figure 3)
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In 1973, French scholar Percheron first reported a very rare variant of thalamic perforating arteries, that is, bilateral thalamic perforating arteries originated from the P1 segment of one posterior cerebral artery, and named it Artery of Percheron (AOP), which was occluded.
It results in bilateral paramedian infarction of the thalamus, with or without involvement of the midbrain
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Percheron arterial infarction accounts for 0.
1%-2% of all acute cerebral infarctions, and 4%-18% of acute thalamic infarctions.
Men are higher than women.
It is a special type of cerebral infarction and is less common in clinical practice
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(Figure 4.
Schematic diagram of the anatomical types of thalamic perforating arteries, the figure is from the literature [1]) There are four anatomical types of thalamic perforating arteries (Figure 4), of which type IIb is the vascular cause of Percheron arterial infarction, when bilateral thalamic perforating arteries originate In the P1 segment of the posterior cerebral artery, which supplies the bilateral ventromedial regions of the thalamus and the upper midbrain, when it is occluded, it can lead to Percheron artery infarction
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Scholars such as Lazzaro divided Percheron arterial infarction into 4 types: type I accounted for 43%, which was bilateral parathalamic infarction and midbrain infarction
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Type II accounted for 38%, with only bilateral infarction in the paramedian area of ​​the thalamus, and no midbrain infarction
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Type III accounted for 14%, that is, bilateral paramedian area of ​​thalamus and anterior thalamus, midbrain infarction
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Type IV accounted for 5%, that is, bilateral paramedian area of ​​thalamus and anterior thalamic infarction, no midbrain infarction
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The typical triad of Percheron arterial infarction is disturbance of consciousness, vertical gaze palsy, and memory disturbance
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Consciousness disturbance is due to bilateral involvement of the nucleus pulposus and the central median nucleus
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Vertical gaze palsy is associated with involvement of the midbrain tectum
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Memory impairment is due to damage to the dorsal medial nucleus of the thalamus, adjacent to the lamellar nucleus
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Scholars at home and abroad reported other rare symptoms including epileptic seizures, mental disorders, dysarthria, external ophthalmoplegia, pupil changes, ataxia and pseudobulbar palsy
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The Percheron artery is very thin and difficult to visualize on cranial MRA and CTA, and can be detected by superselective cerebral angiography in a small number of patients
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The treatment is similar to other ischemic strokes, and the clinical symptoms can be improved to varying degrees after treatment, but most patients still have neurological deficits and the prognosis is generally poor
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Early diagnosis and aggressive treatment are crucial
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In conclusion, Percheron artery infarction is rare in clinical practice, and the complex anatomical structure and diversity of clinical manifestations are easily overlooked
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The disease can leave sequelae symptoms and the prognosis is poor, so it should be diagnosed and treated as soon as possible to improve the quality of life of patients
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References: [1] Nicholas A, Lazzaro, B, Wright, M, Castillo, NJ, Fischbein, CM, Glastonbury, PG, Hildenbrand, RH, Wiggins, EP, Quigley, AG, Osborn.
Artery of percheron infarction: imaging patterns and clinical spectrum.
[J].
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American journal of neuroradiology,2010,31(7):1283-9.
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[2]Zhang Qinli,Chen Yuying,Liu Hong,Wang Yufen,Chen Feng , Gao Zhengke.
Two cases of Percheron arterial infarction[J].
Chinese Journal of Internal Medicine, 2018, 57(6): 454-456.
DOI: 10.
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0578-1426.
2018.
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[3] Liu Yujiao, Gan Fangzhou , Zhang Yongfeng, Zhang Qing.
A case report of Percheron arterial occlusion[J].
Chinese Journal of Stroke, 2019, 14(9): 933-936.
DOI: 10.
3969/j.
issn.
1673-5765.
2019.
09.
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