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*It is only for medical professionals to read for reference.
What is "masking" your eyes? From July 9th to July 11th, the 7th Annual Academic Conference of the Chinese Stroke Society (CSA&TISC 2021) was held in Beijing
.
In the case sharing and expert comment forum on July 9, Dr.
Liang Hui from Hainan Provincial People’s Hospital brought us "What "masked" your eyes? 》The wonderful cases, learn together! Case review Patient Fu Moumou, male, 81 years old
.
Main complaint: paroxysmal confusion, drooping eyelids for 8 hours
.
History of present illness: 8 hours ago, the patient suddenly fell to the ground with unconsciousness while walking.
After being found by passers-by, he contacted 120 and sent him to the emergency department.
It lasted less than 1 hour and his consciousness became clear.
After waking up, his eyes and face drooped and he could not open his eyes at all.
Accompanied by eye movement disorders, he was admitted to the hospital with "acute cerebral infarction"
.
Figure 1: Past history of ptosis of both eyelids: old anterior septal myocardial infarction, post-PCI, atrial flutter, hypertension, and type 2 diabetes
.
Personal history, family history: nothing special
.
Physical examination: cranial nerve: double eyelid drooping, bilateral eyeballs are restricted in inward, upper and lower vision, abduction is acceptable, left pupil diameter is about 2.
5mm, right pupil diameter is about 2mm, light reflection is slow and level Nystagmus
.
Advanced intelligence, consciousness, movement, sensory system, meningeal irritation signs: no abnormalities
.
Bilateral pathological signs (-)
.
Auxiliary examination: biochemical, coagulation, blood, urine, stool routine: no abnormalities
.
Folic acid, vitamin B12, seven items of hyperthyroidism, antinuclear antibodies: no abnormalities
.
Seven male tumors: total prostate specific antigen 5.
401 ng/ml, and there are no abnormalities
.
ECG: 1.
Ectopic rhythm 2.
Atrial flutter (3:1 down)
.
Brain CT: No bleeding was seen
.
How to locate and qualitatively diagnose? ▌ Location diagnosis: The patient is elderly male with acute onset.
According to medical history and physical examination, the patient has ptosis of both eyelids + restricted movement of both eyes up, down, and inward, located in bilateral oculomotor nerve nuclei (midbrain), with both eyes vertical Gaze palsy is located in the vertical eye movement center (midbrain), and the patient's consciousness disturbance is located in the ascending reticulum activation system (brainstem/thalamus)
.
▌ Qualitative diagnosis: The patient is elderly male, with acute onset, ptosis of both eyelids and disturbance of consciousness in a short period of time
.
According to the Midnights principle, the major aspects of cerebrovascular disease, poisoning trauma, acute metabolic abnormality, and infection cannot be ruled out.
We analyze them one by one
.
1.
Patients with poisoning trauma have no history of toxic exposure, no history of trauma, and clinically acute onset.
Therefore, poisoning trauma does not meet the requirements
.
2.
Patients with acute metabolic abnormalities have normal metabolic indicators and are older, so acute metabolic abnormalities are not very similar
.
3.
The infected patient has no symptoms such as fever, blood routine and systemic inflammation indicators have no inflammatory changes, and the infection is not like
.
4.
The onset of cerebrovascular disease is most similar to cerebrovascular disease.
There are risk factors for vascular disease in the past, and there is no hemorrhage in brain CT.
Therefore, ischemic cerebrovascular disease cannot be ruled out
.
Next diagnosis ideas? Considering that the patient’s ischemic cerebrovascular disease cannot be ruled out, the next step requires imaging examination: 12 hours after the onset of the patient’s brain MRI: abnormal signals in the bilateral thalamus
.
Figure 2: Brain MRI (T1, T2) Figure 3: Brain MRI (FLAIR, DWI) According to medical history and physical examination, the patient is located in the midbrain and thalamus lesions.
According to the imaging examination, it is considered as bilateral symmetrical thalamic lesions
.
What should be considered for bilateral thalamic cerebrovascular disease? For bilateral thalamic cerebrovascular disease, the basilar artery apex syndrome must be considered first, but the patient has no obvious lesions in the cerebellum, temporal lobe, and occipital lobe, and the clinical manifestations are not consistent
.
In addition, deep vein thrombosis and percheron arterial infarction must be considered.
In order to determine whether the patient is arterial infarction or venous infarction, we performed cranial MRA+MRV for the patient
.
Figure 4: Craniocerebral MRA+MRV Craniocerebral MRA: The right vertebral artery is not visible, and Craniocerebral MRV: The inferior sagittal sinus is not visible
.
So is the patient an arterial infarction or a venous infarction? We need to analyze the blood supply of the thalamus
.
The blood flow of the thalamus mainly flows into the internal cerebral veins through the thalamic and basal veins, and then into the Galen vein, while the midbrain veins directly enter the Galen vein
.
The blood flow of the inferior sagittal sinus directly enters the straight sinus, and the straight sinus does not supply the thalamus.
Therefore, the lesions of the patient's thalamus and midbrain are not related to the inferior sagittal sinus
.
Figure 5: The blood supply of the thalamus (venous) On the other hand, the thalamus is mainly supplied by four groups of arteries: the nodular thalamic artery, the central parathalamic artery (if it comes from one side, called the percheron artery), the thalamus geniculate artery, and the choroid plexus.
(Choroidal) posterior artery
.
Percheron artery infarction can completely cause the patient's symptoms
.
The patient's final diagnosis: percheron artery infarction
.
Discussion: Parathalamus central artery: also known as the thalamic perforating artery, it mainly supplies the bilateral parathalamic central area, namely the upper midbrain and the parathalamic central part, including the inner plate nucleus group and most of the dorsal medial nucleus
.
When the bilateral paracentral artery originates from one posterior cerebral artery, it is called the percheron artery and originates from the P1 segment of the posterior cerebral artery
.
Figure 6: Schematic diagram of Pecheron artery (left: thalamus and midbrain arteries are usually paired; right: Percheron artery is a single unpaired arterial trunk that originates from the P1 segment of the posterior cerebral artery, towards the midbrain parathalamus and the oral midbrain Blood supply)
.
Percheron arterial infarction is extremely rare.
In 1973, Sehuster reported for the first time a female patient with consciousness disturbance, amnesia, and vertical gaze paralysis as the main features.
The autopsy confirmed bilateral thalamic infarction near the midline
.
Since then, Percheron artery infarction has been reported frequently at home and abroad
.
Percheron arterial infarction is mainly manifested as acute onset, accompanied by varying degrees of consciousness disturbance, vertical gaze paralysis, memory impairment, etc.
CT/MRI examinations of the brain indicate bilateral thalamus near the midline with or without midbrain infarction
.
The diagnosis of Percheron artery infarction is mainly based on clinical manifestations and imaging examinations.
Cerebral angiography can confirm the diagnosis of the disease
.
Figure 6: Schematic diagram of Pecheron artery
What is "masking" your eyes? From July 9th to July 11th, the 7th Annual Academic Conference of the Chinese Stroke Society (CSA&TISC 2021) was held in Beijing
.
In the case sharing and expert comment forum on July 9, Dr.
Liang Hui from Hainan Provincial People’s Hospital brought us "What "masked" your eyes? 》The wonderful cases, learn together! Case review Patient Fu Moumou, male, 81 years old
.
Main complaint: paroxysmal confusion, drooping eyelids for 8 hours
.
History of present illness: 8 hours ago, the patient suddenly fell to the ground with unconsciousness while walking.
After being found by passers-by, he contacted 120 and sent him to the emergency department.
It lasted less than 1 hour and his consciousness became clear.
After waking up, his eyes and face drooped and he could not open his eyes at all.
Accompanied by eye movement disorders, he was admitted to the hospital with "acute cerebral infarction"
.
Figure 1: Past history of ptosis of both eyelids: old anterior septal myocardial infarction, post-PCI, atrial flutter, hypertension, and type 2 diabetes
.
Personal history, family history: nothing special
.
Physical examination: cranial nerve: double eyelid drooping, bilateral eyeballs are restricted in inward, upper and lower vision, abduction is acceptable, left pupil diameter is about 2.
5mm, right pupil diameter is about 2mm, light reflection is slow and level Nystagmus
.
Advanced intelligence, consciousness, movement, sensory system, meningeal irritation signs: no abnormalities
.
Bilateral pathological signs (-)
.
Auxiliary examination: biochemical, coagulation, blood, urine, stool routine: no abnormalities
.
Folic acid, vitamin B12, seven items of hyperthyroidism, antinuclear antibodies: no abnormalities
.
Seven male tumors: total prostate specific antigen 5.
401 ng/ml, and there are no abnormalities
.
ECG: 1.
Ectopic rhythm 2.
Atrial flutter (3:1 down)
.
Brain CT: No bleeding was seen
.
How to locate and qualitatively diagnose? ▌ Location diagnosis: The patient is elderly male with acute onset.
According to medical history and physical examination, the patient has ptosis of both eyelids + restricted movement of both eyes up, down, and inward, located in bilateral oculomotor nerve nuclei (midbrain), with both eyes vertical Gaze palsy is located in the vertical eye movement center (midbrain), and the patient's consciousness disturbance is located in the ascending reticulum activation system (brainstem/thalamus)
.
▌ Qualitative diagnosis: The patient is elderly male, with acute onset, ptosis of both eyelids and disturbance of consciousness in a short period of time
.
According to the Midnights principle, the major aspects of cerebrovascular disease, poisoning trauma, acute metabolic abnormality, and infection cannot be ruled out.
We analyze them one by one
.
1.
Patients with poisoning trauma have no history of toxic exposure, no history of trauma, and clinically acute onset.
Therefore, poisoning trauma does not meet the requirements
.
2.
Patients with acute metabolic abnormalities have normal metabolic indicators and are older, so acute metabolic abnormalities are not very similar
.
3.
The infected patient has no symptoms such as fever, blood routine and systemic inflammation indicators have no inflammatory changes, and the infection is not like
.
4.
The onset of cerebrovascular disease is most similar to cerebrovascular disease.
There are risk factors for vascular disease in the past, and there is no hemorrhage in brain CT.
Therefore, ischemic cerebrovascular disease cannot be ruled out
.
Next diagnosis ideas? Considering that the patient’s ischemic cerebrovascular disease cannot be ruled out, the next step requires imaging examination: 12 hours after the onset of the patient’s brain MRI: abnormal signals in the bilateral thalamus
.
Figure 2: Brain MRI (T1, T2) Figure 3: Brain MRI (FLAIR, DWI) According to medical history and physical examination, the patient is located in the midbrain and thalamus lesions.
According to the imaging examination, it is considered as bilateral symmetrical thalamic lesions
.
What should be considered for bilateral thalamic cerebrovascular disease? For bilateral thalamic cerebrovascular disease, the basilar artery apex syndrome must be considered first, but the patient has no obvious lesions in the cerebellum, temporal lobe, and occipital lobe, and the clinical manifestations are not consistent
.
In addition, deep vein thrombosis and percheron arterial infarction must be considered.
In order to determine whether the patient is arterial infarction or venous infarction, we performed cranial MRA+MRV for the patient
.
Figure 4: Craniocerebral MRA+MRV Craniocerebral MRA: The right vertebral artery is not visible, and Craniocerebral MRV: The inferior sagittal sinus is not visible
.
So is the patient an arterial infarction or a venous infarction? We need to analyze the blood supply of the thalamus
.
The blood flow of the thalamus mainly flows into the internal cerebral veins through the thalamic and basal veins, and then into the Galen vein, while the midbrain veins directly enter the Galen vein
.
The blood flow of the inferior sagittal sinus directly enters the straight sinus, and the straight sinus does not supply the thalamus.
Therefore, the lesions of the patient's thalamus and midbrain are not related to the inferior sagittal sinus
.
Figure 5: The blood supply of the thalamus (venous) On the other hand, the thalamus is mainly supplied by four groups of arteries: the nodular thalamic artery, the central parathalamic artery (if it comes from one side, called the percheron artery), the thalamus geniculate artery, and the choroid plexus.
(Choroidal) posterior artery
.
Percheron artery infarction can completely cause the patient's symptoms
.
The patient's final diagnosis: percheron artery infarction
.
Discussion: Parathalamus central artery: also known as the thalamic perforating artery, it mainly supplies the bilateral parathalamic central area, namely the upper midbrain and the parathalamic central part, including the inner plate nucleus group and most of the dorsal medial nucleus
.
When the bilateral paracentral artery originates from one posterior cerebral artery, it is called the percheron artery and originates from the P1 segment of the posterior cerebral artery
.
Figure 6: Schematic diagram of Pecheron artery (left: thalamus and midbrain arteries are usually paired; right: Percheron artery is a single unpaired arterial trunk that originates from the P1 segment of the posterior cerebral artery, towards the midbrain parathalamus and the oral midbrain Blood supply)
.
Percheron arterial infarction is extremely rare.
In 1973, Sehuster reported for the first time a female patient with consciousness disturbance, amnesia, and vertical gaze paralysis as the main features.
The autopsy confirmed bilateral thalamic infarction near the midline
.
Since then, Percheron artery infarction has been reported frequently at home and abroad
.
Percheron arterial infarction is mainly manifested as acute onset, accompanied by varying degrees of consciousness disturbance, vertical gaze paralysis, memory impairment, etc.
CT/MRI examinations of the brain indicate bilateral thalamus near the midline with or without midbrain infarction
.
The diagnosis of Percheron artery infarction is mainly based on clinical manifestations and imaging examinations.
Cerebral angiography can confirm the diagnosis of the disease
.
Figure 6: Schematic diagram of Pecheron artery
