Does thalamic infarction cause "dementia"?

*For medical professional reading reference only

Come and listen to the big coffee to explain the real case!

According to the "China Stroke Report" released in 2020, about 1/3 of stroke patients in China will experience post-stroke cognitive impairment (PSCI) - PSCI refers to the clinical symptoms of stroke within 6 months after the clinical event.

Recently, it coincided with the national online tour of "PSCI Management Expert Consensus (2021 Edition)", Professor Zhang Haining from the Neurology Cognitive Impairment Diagnosis and Treatment Center of the First Hospital of Jilin University, shared with us two clinical cases of PSCI , let us pick out one of the classic examples and learn together: in the face of risk groups, how to conduct early screening for PSCI in clinical practice, so as to intervene as soon as possible, and then delay or avoid the cognitive decline of stroke patients!

Case: thalamic infarction leading to cognitive decline

▌ Case introduction:

The patient, male, 64-year-old retired clerk, graduated from junior high school, right-handed

Chief Complaint: Memory loss, slow response for 2 days

• No significant increase or decrease in body weight recently, normal living ability before onset, and memory loss without obvious incentive 2 days before admission;

  
  

• Do not know the refrigerator on the day of onset, accompanied by unsatisfactory words and slow response;

  
  

• During the course of the disease, there is no fever, convulsions, physical inactivity, increased sleep, no fluctuating symptoms, no poisoning, no hypoglycemia such as amaurosis, palpitation, and profuse sweating;

  
  

• She was admitted to the hospital with cerebral infarction after performing relevant examinations in the emergency department

  
  

▌ Past history:

• Fundus hemorrhage in June 2013 and 2021;

• Deny the history of hypertension, diabetes, coronary heart disease, stroke, headache, etc.
  ;

• No smoking or alcohol addiction, no family history
  .
  
  

▌ Physical examination on admission:

• Blood pressure 118/61mmHg, heart rate 60 beats/min;

• Clear and clear language, recent memory decline, directional ability is acceptable;

• Bilateral pupils are equal in size, 3.
  0mm in diameter, sensitive to direct and indirect light reflection, and the eyes move flexibly in all directions;

• The bilateral forehead lines and nasolabial folds are symmetrical and equal in depth, and the tongue sticks out in the middle;

• The muscle strength of the four limbs is grade 5, the muscle tension is normal, and there is no abnormality in the ataxia examination.
  

• Pathological reflexes were not elicited, no items were strong, and Kernig's sign was negative
  .
  
  

In addition, the patient's blood glucose, blood ammonia, surgical synthesis, thyroid function, folic acid B12 were normal, and there was no microbleeding on head _SWI
.

So is there any risk of PSCI in the patient? Let's look at the picture below.
Let's listen to Professor Zhang Haining's assessment!

Figure 1 MRI of the patient's brain

As can be seen from the above image, the patient has a left thalamic infarction with white matter changes
.

The patient had significant infarction in the dominant hemisphere and had a burden of cerebrovascular disease
.

The patients' baseline Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores were 22 for MMSE and 17 for MoCA, respectively
.

Professor Zhang Haining pointed out that from the point of view of the scale score, the patient already belonged to the high-risk group of PSCI at the time of early screening!

So, whether the lesions of the thalamus will have symptoms of cognitive decline? Professor Zhang Haining answered this: thalamic infarction may mainly occur in the four main blood supply arteries of the thalamus, these four arteries are the thalamonodular artery, the paracentral artery, the thalamogenic artery and the retrochoroidal artery
.

The thalamic nodular arteries and paracentral arteries are the most obvious ones whose occlusion can cause cognitive decline in patients
.

In this case, the infarction occurred mainly in the thalamonodular artery, and therefore showed marked cognitive decline at the time of onset
.

Symptoms of infarction in 4 feeding arteries,

Are you clear?

From superficial to deep, Professor Zhang Haining also made a further introduction on the symptoms of blockage of the four main blood supply arteries of the thalamus:

① thalamonodular artery

THA usually presents with cognitive impairment, behavioral abnormalities, aphasia, and visual neglect
.

Among them, the dominant hemisphere was affected by cognitive dysfunction mainly with recent memory loss, and the non-dominant hemisphere was affected by visual neglect; behavioral abnormalities were manifested as lack of will and personality changes
.

The patient in this case presented with clinically consistent symptoms of a left nodular artery infarction with dominant hemisphere involvement
.

② Parathalamic artery

The main manifestations of ischemic stroke in the paramedian artery supply area are somnolence, cognitive impairment, psychiatric symptoms, ocular symptoms, aphasia, and asterixis
.

Among them, cognitive dysfunction is more common, also known as thalamic dementia, which manifests as disorientation and anterograde amnesia
.

③Thalamus geniculate artery and retrochoroidal artery

The most common ischemic stroke in the geniculate body arterial supply area is thalamic ischemic stroke, namely thalamic syndrome.
The typical clinical manifestations are paresthesia and hemiparesis, mainly with deep sensory disturbance, and paresthesia can involve the face and limbs
.

The manifestations of ischemic stroke in the blood supply area of ​​the retrochoroidal artery include visual field defect, deep sensory disturbance, hemiparesis, transient amnesia, and aphasia.
The visual field defect is mainly fan-shaped, and upper quadrant blindness or lower quadrant blindness can also be seen, and its compensation is relatively relative.
Good, the relevant literature reports are relatively few
.

On treatment: "Regular follow-up is important"

Back to this case, when talking about the treatment of the patient, Professor Zhang Haining first emphasized: "We must strictly follow up
.

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• Deputy Chief Physician, Associate Professor, Doctor of Medicine, Master Supervisor, Department of Neurology, First Hospital of Jilin University

• Postdoc at University of Michigan

• Member of the Youth Committee of the Chinese Gerontological Society Cognitive Impairment Committee

• Secretary of the Cognitive Impairment Group, Neurology Branch of Jilin Medical Association

• He has been engaged in the research of vascular cognitive impairment, and his doctoral research project won the third prize of Jilin Province Science and Technology Progress Award

• Published many papers in domestic and foreign academic journals

• In 2015, it was supported by the Outstanding Young Teachers Support Program of Jilin University

• Served as the secretary of the eight-year textbook of the third edition of "Neurology" by the People's Medical Publishing House and the editorial board of the related exercise collections

Source of this articleNeurology Channel of the medical community.
This article is organized by the conference record group of the medical community.
This article is reviewed by Professor Zhang Haining.