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Stuck with a drowsy patient, evoke the Percheron
Sanjith Aaron, Sunithi Mani, A T Prabhakar
1Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.
Insights
Strokes from the artery of Percheron (AOP) are rare but serious. Magnetic resonance imaging (MRI) is crucial for diagnosing these thalamic infarcts, often presenting with consciousness disorders.
Area of Science:
- Neurology
- Radiology
- Vascular Neurology
Background:
- Cerebral circulation variants can cause difficult-to-diagnose strokes.
- A high index of suspicion is necessary for rare stroke types.
- This series focuses on artery of Percheron (AOP) occlusion strokes.
Purpose of the Study:
- To analyze the clinical and radiological features of artery of Percheron (AOP) infarction.
- To highlight the diagnostic challenges and imaging characteristics of AOP strokes.
- To identify common etiological factors and outcomes in AOP infarction.
Main Methods:
- Retrospective analysis of 17 patients with AOP infarction from 2002-2014.
- Review of computerized discharge summaries, outpatient records, and PACS imaging.
- Correlation of clinical presentation, MRI findings, and etiological factors (TOAST criteria).
Main Results:
- AOP infarction accounted for 0.47% of all strokes (17/3589).
- Common symptoms included disorders of consciousness (94%), gaze (53%), and memory impairment (24%).
- MRI revealed bilateral paramedian thalamic infarcts in all patients; CT was less sensitive (55%).
- Cardioembolic (47%) and small vessel occlusion (41%) were primary causes.
- Mortality was 12%, with 47% achieving a modified Rankin score ≤2 at 6 months.
Conclusions:
- Artery of Percheron infarcts are a critical differential diagnosis for altered consciousness.
- Magnetic resonance imaging (MRI) is the preferred diagnostic modality.
- Active investigation for embolic sources is recommended.
Background:
Strokes caused by normal variants of the cerebral circulation can be difficult to diagnose, hence a high index of suspicion is needed. This case series discusses the clinical and radiological aspects of one such stroke caused by occlusion of the artery of Percheron (AOP).
Materials And Methods:
Computerized discharge summaries, outpatient records and imaging from picture archiving and communication system (PACS, GE), of patients with AOP infarction over a period of 12-years (2002-2014) were identified and their clinical and radiological features analyzed.
Results:
Of 3589 strokes (both ischemic and hemorrhagic), 17 (0.47%) were due to AOP infarction. Their mean age was 50 years (range: 31-72 years). Disorders of consciousness (94%) were the most common presenting symptoms followed by gaze (53%) and memory impairment (24%). At follow-up, 2/17 (12%) patients developed extrapyramidal features. All patients had bilateral paramedian thalamic infarcts on magnetic resonance imaging (MRI). Associated anterior thalamic (5/17; 30%) and mid brain (10/17; 59%) infarcts were also seen. CT scan done in 11/17 patients prior to the MRI picked up only 6/11 (55%) of these infarcts. The most common etiological factors detected using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria were cardio embolic (8/17; 47%) followed by small vessel occlusion (7/17; 41%). Mortality occurred in 2/17 (12%) patients. At 6 months, a modified Rankin score of 2 or less was seen in 8/17 (47%) patients.
Conclusions:
Artery of Percheron infarcts should be considered in the differential diagnosis of patients presenting with sudden alterations in consciousness. MRI should be the investigation of choice. An embolic etiology should be actively looked for.