Multiple variant type thalamic infarcts: pure and combined types

Characteristics of Multiple Acute Concomitant Cerebral Infarcts Involving Different Arterial Territories

(1) Background: Multiple acute concomitant cerebral infarcts (MACCI) are relatively uncommon. Data regarding the characteristics and outcomes of patients with MACCI are lacking. We, therefore, aimed to characterize the clinical features of MACCI. (2) Methods: Patients with MACCI were identified from a prospective registry of stroke patients admitted to a tertiary teaching center. Patients with an acute single embolic stroke (ASES) involving only one vascular bed served as controls. (3) Results: MACCI was diagnosed in 103 patients who were compared to 150 patients with ASES. MACCI patients were significantly older (p = 0.010), more often had a history of diabetes (p = 0.011) and had lower rates of ischemic heart disease (p = 0.022). On admission, MACCI patients had significantly higher rates of focal signs (p < 0.001), an altered mental state (p < 0.001) and seizures (p = 0.036). The favorable functional outcome was significantly less common in patients with MACCI (p = 0.006). In the multivariable analysis, MACCI was associated with lower chances of achieving favorable outcomes (odds ratio: 0.190, 95% CI: 0.070-0.502). (4) Conclusions: There are important differences in clinical presentation, comorbidities and outcomes between MACCI and ASES. MACCI is less often associated with favorable outcomes and could represent a more severe form of a stroke compared with a single embolic stroke.

Characterization of Macular Structural and Microvascular Changes in Thalamic Infarction Patients: A Swept-Source Optical Coherence Tomography-Angiography Study

Background: The retina and brain share similar neuronal and microvascular features. We aimed to investigate the retinal thickness and microvasculature in patients with thalamic infarcts compared with control participants. Material and methods: Swept-source optical coherence tomography (SS-OCT) was used to image the macular thickness (retinal nerve fiber layer, RNFL; ganglion cell-inner plexiform layer, GCIP), while OCT angiography was used to image the microvasculature (superficial vascular plexus, SVP; intermediate capillary plexus, ICP; deep capillary plexus, DCP). Inbuilt software was used to measure the macular thickness (µm) and microvascular density (%). Lesion volumes were quantitively assessed based on structural magnetic resonance images. Results: A total of 35 patients with unilateral thalamic infarction and 31 age−sex-matched controls were enrolled. Compared with control participants, thalamic infarction patients showed a significantly thinner thickness of RNFL (p < 0.01) and GCIP (p = 0.02), and a lower density of SVP (p = 0.001) and ICP (p = 0.022). In the group of patients, ipsilateral eyes showed significant reductions in SVP (p = 0.033), RNFL (p = 0.01) and GCIP (p = 0.043). When divided into three groups based on disease duration (<1 month, 1−6 months, and >6 months), no significant differences were found among these groups. After adjusting for confounders, SVP, ICP, DCP, RNFL, and GCIP were significantly correlated with lesion volume in patients. Conclusions: Thalamic infarction patients showed significant macular structure and microvasculature changes. Lesion size was significantly correlated with these alterations. These findings may be useful for further research into the clinical utility of retinal imaging in stroke patients, especially those with damage to the visual pathway.

Topographic evaluation of bithalamic infarcts: Are these due to occlusion of the artery of Percheron?

Occlusion of the artery of Percheron (AoP) causes bithalamic paramedian infarct (BTPI). Although it can be diagnosed easily in its pure form, it can be underdiagnosed in cases with concomitant extrathalamic acute infarcts (plus-BTPI) as it may be difficult to determine whether BTPI is due to occlusion of AoP or two different paramedian arteries even with conventional angiography. This study was performed to highlight plus-BTPI that could result from occlusion of AoP rather than of two distinct paramedian arteries using topographic evaluation of bithalamic infarcts. We retrospectively reviewed imaging and clinical databases for patients admitted to radiology department between 2013 and 2019. Two radiologists independently evaluated the results of imaging studies, and findings reached by consensus were used in the analysis. This retrospective review yielded 34 patients with bithalamic infarct. Each affected thalamic vascular region was investigated separately. Any patient could have more than 2 different vascular zone infarct. The affected thalamic vascular territories were paramedian (n = 24), inferolateral (n = 13), anterior (n = 10), and posterior (n = 7). When we evaluated bithalamic infarcts in terms of symmetrically affected territories, the distribution of symmetric affected territories was as: paramedian (n = 18), inferolateral (n = 2), anterior (n = 1), and posterior (n = 1). BTPI had a 4.5-fold higher frequency than the sum of symmetric involvement of other territories (p = 0.0552, OR = 4.5,95%CI 0.93-21.5). In addition, mesencephalic involvement was only observed in BTPI, and not in other patterns (p < 0.001). The fact that in bilateral thalamic infarcts the symmetric involvement of paramedic territory is significantly higher and mesencephalic involvement is seen only in BTPI can suggest that plus-BPTI may develop due to AoP occlusion rather than occlusion of two distinct paramedian arteries.

Neuro-Ophthalmologic Features and Outcomes of Thalamic Infarction: A Single-Institutional 10-Year Experience

BACKGROUND

Neuro-ophthalmologic deficit after thalamic infarction has been of great concern to ophthalmologists because of its debilitating impacts on patients' daily living. We aimed to describe the visual and oculomotor features of thalamic infarction and to delineate clinical outcomes and prognostic factors of the oculomotor deficits from an ophthalmologic point of view.

METHODS

Clinical and neuroimaging data of all participants were retrospectively reviewed. Among the 12,755 patients with first-ever ischemic stroke, who were registered in our Stroke Data Bank between January 2009 and December 2018, 342 were found to have acute thalamic infarcts on MRI, from whom we identified the patients exhibiting neuro-ophthalmologic manifestations including visual, oculomotor, pupillary, and eyelid anomalies.

RESULTS

Forty (11.7%) of the 342 patients with thalamic infarction demonstrated neuro-ophthalmologic manifestations, consisting of vertical gaze palsy (n = 19), skew deviation with an invariable hypotropia of the contralesional eye (n = 18), third nerve palsy (n = 11), pseudoabducens palsy (n = 9), visual field defects (n = 7), and other anomalies such as isolated ptosis and miosis (n = 7). Paramedian infarct was the most predominant lesion of neuro-ophthalmologic significance, accounting for 84.8% (n = 28) of all patients sharing the oculomotor features. Although most of the patients with oculomotor abnormalities rapidly improved without sequelae, 6 (18.2%) patients showed permanent oculomotor deficits. Common clinical features of patients with permanent oculomotor deficits included the following: no improvement within 3 months, combined upgaze and downgaze palsy, and the involvement of the paramedian tegmentum of the rostral midbrain.

CONCLUSIONS

Thalamic infarction, especially in paramedian territory, can cause a wide variety of neuro-ophthalmologic manifestations, including vertical gaze palsy, skew deviation, and third nerve palsy. Although most oculomotor abnormalities resolve spontaneously within a few months, some may persist for years when the deficits remain unimproved for more than 3 months after stroke.

Bilateral thalamic stroke after tonsillectomy in a patient with collateral extracranial anastomosis - case report

Haemorrhage remains the most frequent and serious complication of tonsillectomy. When bleeding is recurrent, gushing, and ceases spontaneously, pseudoaneurysm of the injured artery in the proximity of the tonsillar bed should be suspected. Haemorrhage related to pseudoaneurysm occurs most commonly in the first 30 days after surgery. It can sometimes be excessive and requires a revision procedure such as external carotid artery (ECA) ligation or embolisation. During those procedures, ECA should be checked for possible anastomoses, otherwise the bleeding may persist despite the intervention. We report an unusual case of a patient with recurrent post-tonsillectomy haemorrhage due to pseudoaneurysm of the facial artery, which persisted after ECA ligation because of the presence of collateral occipital-vertebral anastomosis. Due to the recurrence of bleeding episodes, endovascular treatment was implemented. However, the embolisation was complicated by bilateral thalamic stroke with unclear mechanism. This case highlights the importance of anastomosis between ECA and the vertebrobasilar system, both in recurrence of significant post-tonsillectomy bleeding and in potential thromboembolic complications. Therefore, ECA ligation should always be accompanied by exclusion of possible anastomoses. In cases of non-life-threatening bleeding, embolisation seems to be the proper and more selective therapy.

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.

Acute cerebral infarcts in multiple arterial territories associated with cardioembolism

OBJECTIVES

It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism.

MATERIALS AND METHODS

We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories.

RESULTS

MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI.

CONCLUSIONS

Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.

Clinical Features of Thalamic Stroke

OPINION STATEMENT

The thalamus plays an important role in different brain functions including memory, emotions, sleep-wake cycle, executive functions, mediating general cortical alerting responses, processing of sensory (including taste, somatosensory, visual, and auditory) information and relaying it to the cortex, and sensorimotor control. Thalamic stroke, both in isolation and in combination with infarcts involving other structures, are not rare. The functional complexity of the thalami nuclei and the not uncommon normal variations of arteries supply the thalamus induce wide variations in presentation of thalami infarcts. In patients with an unusual collection of deficits difficult to explain by a single lesion, in particular where there is impaired vigilance, thalamic disease should be considered which may mimic several different neurological conditions. By researching the literature, we found that the characteristic stroke syndrome of paramedian thalamic infarction is probably underdiagnosed. In addition to thalamic infarct, thalamic lesions can be caused by deep cerebral venous thrombosis with neuropsychological and radiological features that should be considered in the differential diagnosis of intracranial artery occlusion or bleeding, especially in young patients.

Influences of hyperlipidemia history on stroke outcome; a retrospective cohort study based on the Kyoto Stroke Registry

Background

Although hyperlipidemia is known as a risk factor of stroke, its effects on the outcome are unknown. The aim of the study is to clarify the influences of hyperlipidemia on the stroke early outcome by estimating odds ratio (OR) for sequelae requiring care and hazard ratio (HR) for death.

Methods

A total of 12617 stroke patients registered in the Kyoto Stroke Registry with information on a hyperlipidemia history. We compared patients who had hyperlipidemia history and patients who hadn’t. The OR for remaining sequelae requiring certain care on 30 day after stroke was calculated using a logistic regression in stroke as a whole and in each stroke subtype; cerebral infarction (CI), cerebral hemorrhage (CH) and subarachnoid hemorrhage (SAH). The HR for death within 30 day after stroke was estimated by the Cox regression.

Results

The OR (95% confidence interval) for remaining sequelae 30 days after stroke was 0.66 (0.60-0.73, p < 0.001) in patients with hyperlipidemia history compared with patients without hyperlipidemia history. After stratified by stroke subtypes, it was 0.75 (0.67-0.85, p < 0.001) in CI, 0.59 (0.45-0.77, p < 0.001) in CH and 0.77 (0.43-1.38, p = 0.767) in SAH. The HR (95% confidence interval) for death was 0.39 (0.31-0.48, p < 0.001) in patients with hyperlipidemia history comparing patients without hyperlipidemia history. After stratified by stroke subtypes, it was 0.45 (0.32-0.63, p < 0.001) in CI, 0.64 (0.44-0.93, p = 0.018) in CH and 0.76 (0.47-1.23, p = 0.264) in SAH. Each value was adjusted for age and sex.

Conclusions

This study suggests that the outcome is favorable for patients with hyperlipidemia history in terms of both remaining sequelae and HR for death. A factor which increases the incidence of the disease could influence on the severity of the disease in a favorable way.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0297-1) contains supplementary material, which is available to authorized users.