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Schön F, Wahl H, Grey A, Krukowski P, Müller A, Puetz V, Linn J, Kaiser DPO. Improved Visualization and Quantification of Net Water Uptake in Recent Small Subcortical Infarcts in the Thalamus Using Computed Tomography. Diagnostics (Basel) 2023; 13:3416. [PMID: 37998551 PMCID: PMC10670270 DOI: 10.3390/diagnostics13223416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Diagnosing recent small subcortical infarcts (RSSIs) via early computed tomography (CT) remains challenging. This study aimed to assess CT attenuation values (Hounsfield Units (HU)) and net water uptake (NWU) in RSSI and explore a postprocessing algorithm's potential to enhance thalamic RSSI detection. We examined non-contrast CT (NCCT) data from patients with confirmed thalamic RSSI on diffusion-weighted magnetic resonance imaging (DW-MRI) between January 2010 and October 2017. Co-registered DW-MRI and NCCT images enabled HU and NWU quantification in the infarct area compared to unaffected contralateral tissue. Results were categorized based on symptom onset to NCCT timing. Postprocessing using window optimization and frequency-selective non-linear blending (FSNLB) was applied, with interpretations by three blinded Neuroradiologists. The study included 34 patients (median age 70 years [IQR 63-76], 14 women). RSSI exhibited significantly reduced mean CT attenuation compared to unaffected thalamus (29.6 HU (±3.1) vs. 33.3 HU (±2.6); p < 0.01). Mean NWU in the infarct area increased from 6.4% (±7.2) at 0-6 h to 16.6% (±8.7) at 24-36 h post-symptom onset. Postprocessed NCCT using these HU values improved sensitivity for RSSI detection from 32% in unprocessed CT to 41% in FSNLB-optimized CT, with specificities ranging from 86% to 95%. In conclusion, CT attenuation values and NWU are discernible in thalamic RSSI up to 36 h post-symptom onset. Postprocessing techniques, particularly window optimization and FSNLB, moderately enhance RSSI detection.
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Affiliation(s)
- Felix Schön
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Hannes Wahl
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Arne Grey
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Pawel Krukowski
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Angela Müller
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jennifer Linn
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniel P. O. Kaiser
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Perovnik M, Pretnar Oblak J, Frol S. A Case Series of Four Patients with Artery of Percheron Occlusion over a Three-Month Period. Neurol Int 2023; 15:1352-1358. [PMID: 37987458 PMCID: PMC10661246 DOI: 10.3390/neurolint15040085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023] Open
Abstract
Here, we present a case series of four patients diagnosed with acute ischaemic stroke due to occlusion of the artery of Percheron (AOP), a rare stroke variant, observed in a single emergency centre within a three-month period. AOP occlusion is characterized by bilateral thalamic infarction with or without involvement of the mesencephalon. The presenting symptoms are diverse and not specific, but commonly include disturbance of consciousness, memory impairment, and vertical gaze palsy. In addition, due to the location of the infarction, imaging recognition is challenging and AOP occlusion often remains undiagnosed. This paper emphasizes the necessity of early recognition and appropriate management of AOP occlusion to significantly impact patient outcomes. Moreover, we argue that the condition might be more common than previously thought and that misdiagnosis or delay in diagnosis may lead to inappropriate treatment and potential failure to apply thrombolysis within the required timeframe.
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Affiliation(s)
- Matej Perovnik
- Department of Vascular Neurology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.P.); (J.P.O.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.P.); (J.P.O.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.P.); (J.P.O.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Scharf AC, Gronewold J, Eilers A, Todica O, Moenninghoff C, Doeppner TR, de Haan B, Bassetti CL, Hermann DM. Depression and anxiety in acute ischemic stroke involving the anterior but not paramedian or inferolateral thalamus. Front Psychol 2023; 14:1218526. [PMID: 37701875 PMCID: PMC10493383 DOI: 10.3389/fpsyg.2023.1218526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023] Open
Abstract
Background and objectives Emotional and cognitive deficits are prevalent in strokes involving the thalamus. In contrast to cognitive deficits, emotional deficits have not been studied prospectively in isolated thalamic stroke. Methods In 37 ischemic thalamic stroke patients (57.0 [50.0; 69.5] years [median (Q1; Q3)], 21 males, 5 anterior, 12 paramedian, 20 inferolateral vascular territory), and 37 non-stroke control patients matched for age and sex, we prospectively examined depression, anxiety, activities of daily living, and quality of life at 1, 6, 12, and 24 months post-stroke using the Hospital-Anxiety-and-Depression Scale (HADS), Nürnberger-Alters-Alltagsaktivitäten scale (NAA), and Short Form-36 (SF36) questionnaire. Voxel-based lesion-symptom mapping (VLSM) and lesion-subtraction analyzes were performed to determine associations between questionnaire scores and thalamic stroke topography. Results At 1 month post-stroke, anterior thalamic stroke patients had higher depression scores [8.0 (7.5; 10.5)] than paramedian [4.5 (1.0; 5.8)] and inferolateral [4.0 (1.0; 7.0)] thalamic stroke patients. Furthermore, anterior thalamic stroke patients had higher anxiety scores [11.0 (8.0; 14.5)] than their matched controls [2.5 (2.0; 2.5)], paramedian [4.5 (1.0; 5.8)] and inferior [4.0 (1.0; 7.0)] thalamic stroke patients. Depression and anxiety scores in anterior thalamic stroke patients remained high across the follow-up [depression: 9.0 (3.5; 13,8); anxiety:10.05 (2.8, 14.5)].Physical health assessed by SF36 was intact in anterior [1 month post-stroke: T-score = 55.9 (37.0; 57.6)] but reduced in inferolateral [44.5(32.4; 53.1)] thalamic stroke, whereas mental health was reduced in anterior thalamic stroke [32.0 (29.8; 47.3)].VLSM confirmed that voxels in the anterior thalamus around Montreal Neurological Institute (MNI) coordinates X = -8, Y = -12, Z = 2 were more often affected by the stroke in depressed (HADS-score ≥ 8) than non-depressed (HADS-score < 8) patients and voxels around coordinates X = -10, Y = -12, Z = 2 were more often affected in anxious (HADS-score ≥ 8) than non-anxious (HADS-score < 8) patients. Conclusion Anterior, but not paramedian or inferolateral thalamic stroke was associated with depression and anxiety. Even though our results are mostly significant in the left thalamus, this observation on stroke laterality might be confounded by the fact that the right hemisphere was underrepresented in our study.
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Affiliation(s)
- Anne-Carina Scharf
- Department of Neurology, Institute of Vascular Neurology, Dementia and Ageing Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Janine Gronewold
- Department of Neurology, Institute of Vascular Neurology, Dementia and Ageing Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andres Eilers
- Department of Neurology, Institute of Vascular Neurology, Dementia and Ageing Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Olga Todica
- Department of Neurology, Institute of Vascular Neurology, Dementia and Ageing Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Moenninghoff
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thorsten R. Doeppner
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Bianca de Haan
- Division of Psychology, Department of Life Sciences, Centre for Cognitive Neuroscience, Brunel University, London, United Kingdom
| | | | - Dirk M. Hermann
- Department of Neurology, Institute of Vascular Neurology, Dementia and Ageing Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Sheikh Hassan M, Osman Sidow N, Mohamed Ali A, Osman MF, Ahmed Ibrahim A, Abdirahman Ahmed S. Agitation and somnolence by bilateral paramedian thalamic infarct. Clin Case Rep 2023; 11:e7590. [PMID: 37346883 PMCID: PMC10279932 DOI: 10.1002/ccr3.7590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/23/2023] Open
Abstract
Key Clinical Message Bilateral thalamic infarction in paramedian artery territory may present with severe acute illness, confusion, coma and memory impairment. However, subtle clinical presentation as in our case should alert the clinician to consider such a diagnosis as it can be associated with good prognosis. Abstract Bilateral thalamic infarct is a rare form of stroke. Mostly thalamic infarcts are unilateral. In most cases, bilateral thalamic infarction leads to cognitive dysfunction, opthalmoparesis, conscious impairment, behavioral disturbance, and corticospinal dysfunction. Here, we describe the case of a 75-year-old male patient who presented to the emergency department of our hospital with agitation and somnolence for one day. He had poorly controlled hypertension. There was no previous history of stroke, diabetes mellitus, hyperlipidemia, known cardiac disease, or smoking history. There was no seizure, recent headache, or visual disturbance. The patient was somnolent and not oriented to time, person, or place. Neurological examination did not show any focal weakness or vertical eye movement restrictions. Other systemic examinations, including those of the respiratory and cardiovascular systems, were unremarkable. Extensive laboratory investigations excluded potential metabolic, infectious, endocrine, or toxic etiologies. The patient did not have any recent history of drug misuse, including benzodiazepines. Brain MRI with diffusion-weighted imaging showed an acute bilateral thalamic infarct. Cerebral angiography was unremarkable. The patient was treated with low molecular weight heparin 60 mg subcutaneously, aspirin 300 mg daily, and haloperidol 5 mg twice daily for agitation. After two weeks of intrahospital treatment, his condition improved (consciousness and orientation massively improved).
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Affiliation(s)
- Mohamed Sheikh Hassan
- Department of NeurologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
| | - Nor Osman Sidow
- Department of NeurologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
| | - Abdiladhif Mohamed Ali
- Department of NeurologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
| | - Mohamed Farah Osman
- Department of NeurologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
| | - Abdiwahid Ahmed Ibrahim
- Department of NeurologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
| | - Said Abdirahman Ahmed
- Department of CardiologyMogadishu Somalia Turkish Training and Research HospitalMogadishuSomalia
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Mbodji AB, Faye I, Diop NR, Ndiaye M. Weber's syndrome revealing a Percheron artery infarction: A case report. Clin Case Rep 2023; 11:e7268. [PMID: 37102094 PMCID: PMC10123313 DOI: 10.1002/ccr3.7268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023] Open
Abstract
Key Clinical Message Weber's syndrome revealing a Percheron artery infarction is a rare clinical occurrence. Its diagnosis requires careful clinical examination and brain MRI, which is the gold standard for diagnosis. If this is not available, combined cerebral CT scan with a CT angiography of supra-aortic arteries may be useful for the diagnosis. Abstract Percheron's artery (PA) occlusion is an uncommon type of stroke involving paramedian thalamus and/or midbrain infarction. It accounts for 4%-18% of all thalamic infarcts and 0.1%-2% of all strokes. Its clinical manifestations are variable and its mode of presentation as Weber's syndrome is exceptional due to the unusual clinical presentation.
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Ciacciarelli A, Francalanza I, Giammello F, Galletta K, Toscano A, Musolino RF, Granata F, La Spina P. Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis. Neurol Sci 2023:10.1007/s10072-023-06681-4. [PMID: 36800102 DOI: 10.1007/s10072-023-06681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Occlusion of artery of Percheron (AOP), a rare variant of paramedian branches of posterior cerebral artery, results in a characteristic pattern of ischemic lesions in bilateral paramedian thalami with or without midbrain and anterior thalami involvement. AIM To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. METHODS We retrospectively search in our stroke center database, patients with ischemic lesions in the AOP distribution. We collected clinical features and time between hospital admission and diagnosis. Imaging findings were categorized following a pre-selected classification. RESULTS Of 2830 ischemic stroke admitted in our center, we identified 15 patients with AOP infarction (0.53%). Clinical manifestations were variable, but oculomotor disturbances, particularly vertical gaze palsy, were the most observed, followed by consciousness impairment, varying from drowsiness to coma. The most frequent imaging pattern was bilateral paramedian thalamic infarction with midbrain infarction, and the V-sign was recognized in 6 cases from this group. In 8 patients a fetal origin of the PCA was observed. The average time from first hospital admission to diagnosis was 28.09 h. CONCLUSIONS The prevalence of AOP infarction in our center was 0.53%. Diagnosis of AOP infarction can be challenging and should be suspected in case of sudden altered consciousness.
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Affiliation(s)
- Antonio Ciacciarelli
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Isabella Francalanza
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fabrizio Giammello
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy.
| | - Karol Galletta
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Toscano
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Rosa Fortunata Musolino
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Francesca Granata
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Paolino La Spina
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
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Topographic Mapping of Isolated Thalamic Infarcts Using Vascular and Novel Probabilistic Functional Thalamic Landmarks. Clin Neuroradiol 2022; 33:435-444. [DOI: 10.1007/s00062-022-01225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 10/02/2022] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose
We aimed to re-evaluate the relationship between thalamic infarct (TI) localization and clinical symptoms using a vascular (VTM) and a novel functional territorial thalamic map (FTM).
Methods
Magnetic resonance imaging (MRI) and clinical data of 65 patients with isolated TI were evaluated (female n = 23, male n = 42, right n = 23, left n = 42). A VTM depicted the known seven thalamic vascular territories (VT: inferolateral, anterolateral, inferomedial, posterior, central, anteromedian, posterolateral). An FTM was generated from a probabilistic thalamic nuclei atlas to determine six functionally defined territories (FT: anterior: memory/emotions; ventral: motor/somatosensory/language; medial: behavior/emotions/nociception, oculomotor; intralaminar: arousal/pain; lateral: visuospatial/somatosensory/conceptual and analytic thinking; posterior: audiovisual/somatosensory). Four neuroradiologists independently assigned diffusion-weighted imaging (DWI) lesions to the territories mapped by the VTM and FTM. Findings were correlated with clinical features.
Results
The most frequent symptom was a hemisensory syndrome (58%), which was not specific for any territory. A co-occurrence of hemisensory syndrome and hemiparesis had positive predictive values (PPV) of 76% and 82% for the involvement of the inferolateral VT and ventral FT, respectively. Thalamic aphasia had a PPV of 63% each for involvement of the anterolateral VT and ventral FT. Neglect was associated with involvement of the inferolateral VT/ventral FT. Interrater reliability for the assignment of DWI lesions to the VTM was fair (κ = 0.36), but good (κ = 0.73) for the FTM.
Conclusion
The FTM revealed a greater reproducibility for the topographical assignment of TI than the VTM. Sensorimotor hemiparesis and neglect are predictive for a TI in the inferolateral VT/ventral FT. The hemisensory syndrome alone does not allow any topographical assignment.
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Tu T, Song Z, Ma Y, Yang C, Su X, He C, Li G, Hong T, Sun L, Hu P, Zhang P, Ye M, Zhang H. Adult dural arteriovenous fistulas in Galen region: More to be rediscovered. Front Neurol 2022; 13:957713. [PMID: 36388187 PMCID: PMC9650976 DOI: 10.3389/fneur.2022.957713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/26/2022] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) in the Galen region are the most deeply located and most complex type of dural arteriovenous fistulas. However, cases of DAVFs in this region have not been well described. Thus, we aimed to summarize the characteristics of Galenic DAVFs involving clinical symptoms, anatomical architecture, and drainage patterns, providing experientially therapeutic strategies for these lesions based on our 20 years of clinical experience. METHODS We retrospectively examined 31 patients with Galenic DAVFs between January 2000 and June 2021. A comprehensive analysis was carried out based on the symptoms, imaging features, feeding arteries, draining veins, number and location of the fistulas, choice of treatment methods, and prognosis assessment. RESULTS Twenty-nine patients received endovascular embolization, and no perioperative deaths occurred. A transarterial approach was performed in 27 patients, and a combined transarterial and transvenous approach in one. And in one case, access was established by surgical drilling and embolization was done via the venous route. Twenty-four cases were completely obliterated after first embolization, and another five cases received a second period treatment. Only one patient developed cognitive dysfunction after embolization, and the outcomes of the remaining patients were improved at long-term follow-up. CONCLUSION The understanding of symptoms of non-hemorrhagic neurological deficits in DAVF needs to be further clarified. Lesions with pial feeders may be considered first when determining surgical orders. Multi-approach and multi-stage embolization would be safe and effective. Excessive embolization and deep-vein system obstruction should be avoided. Approach creation by surgery would be an innovative interventional therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Ji S, Sun H, Jin X, Chen B, Zhou J, Zhao J, Liang X, Shen W, Zhang Y, Chan P. Cognitive recovery in patients with post-stroke subjective cognitive complaints. Front Neurol 2022; 13:977641. [PMID: 36237629 PMCID: PMC9551021 DOI: 10.3389/fneur.2022.977641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose The objective cognitive trajectory in patients with post-stroke subjective cognitive complaints (SCC) over time remained unknown. We investigated cognitive outcomes in patients with SCC within 1 year after stroke, and determined factors associated with cognitive recovery. Methods This study included 599 patients with a clinical diagnosis of post-stroke SCC and evidence of cognitive deficits including Clinical Dementia Rating Scale (CDR) = 0.5, Montreal Cognitive Assessment (MoCA) score <26, and Mini–Mental State Examination score >17 (illiterate) or >20 (primary school) or >24 (junior school or above). Neuropsychological assessment was performed at baseline (2 weeks to 6 months after stroke) and 6-month follow-up visit. Cognitive recovery was operationalized as unimpaired cognition (MoCA score ≥26 and CDR = 0) after 6 months. Factors associated with recovery were defined through logistic regression analysis. Results After 6 months, 583 patients completed the follow-up with 80 (13.72%) presenting cognitive recovery, among which, 22 (9.48%) cases reported SCC within 2 weeks after stroke, six (10%) at 15–30 days, 13 (15.12%) at 31–60 days, 10 (16.13%) at 61–90 days, five (10.42%) at 91–120 days, nine (23.08%) at 121–150 days, and 15 (26.79%) at 151–180 days. Compared to those reported cognitive complaints at 151–180 days after stroke, patients with early post-stroke SCC had poorer cognitive recovery, which was only significant in individuals with high level of education. Male sex, higher baseline MoCA scores, coffee intake and thalamus lesions were independently associated with high chance of cognitive recovery. Conclusions Although post-stroke SCC contributes to persisting objective cognitive deficits, some patients presented cognitive recovery within 1 year after stroke. Patients with a high education level reporting SCC at earlier stage after stroke had poorer cognitive recovery. Male, higher baseline MoCA scores, coffee intake and thalamus lesions appear to independently predict cognitive recovery.
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Affiliation(s)
- Shaozhen Ji
- Department of Neurology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Hong Sun
- Department of Neurobiology, Neurology and Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing Institute of Geriatrics, Beijing, China
| | - Xianglan Jin
- Department of Neurology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Baoxin Chen
- Department of Neurology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Zhou
- Department of Neurology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiayi Zhao
- Department of Neurology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiao Liang
- Department of Neurology, China Academy of Chinese Medical Sciences Xiyuan Hospital, Beijing, China
| | - Wei Shen
- Department of Neurology, China Academy of Chinese Medical Sciences Xiyuan Hospital, Beijing, China
| | - Yunling Zhang
- Department of Neurology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, China Academy of Chinese Medical Sciences Xiyuan Hospital, Beijing, China
- *Correspondence: Yunling Zhang
| | - Piu Chan
- Department of Neurobiology, Neurology and Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing Institute of Geriatrics, Beijing, China
- Piu Chan
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Cai L, Wang Q, Cui B, Wang P. Artery of Percheron Occlusion in China: A Case Report and Chinese Literature Review. Neurologist 2022; 27:214-217. [PMID: 34842578 PMCID: PMC9257057 DOI: 10.1097/nrl.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The artery of Percheron (AOP) is a rare anatomical variant in which bilateral paramedian thalami are supplied by a single vascular branch arising from the P1 segment of the posterior cerebral artery. We present a case of AOP occlusion presenting as loss of consciousness and summarize the literature in Chinese to find the clinical characteristics. CASE REPORT An 83-year-old woman was found unconscious for 1 day at home and was sent to the hospital the next day. Cerebral magnetic resonance imaging on day 1 of the patient showed a recent bilateral paramedian thalamic infarction. Simultaneously, magnetic resonance angiography found evident artery stenosis of the right P1 segment of the posterior cerebral artery, suggesting that the patient was diagnosed with AOP occlusion. Since the patient has missed the best time for thrombolytic therapy, anticoagulant therapy was given immediately; as the patient was then found to have pulmonary infections, antibiotic therapy was also initiated. The neurological status of this patient improved very slow. In about 2 weeks, the patient becomes more conscious but still could not speak or move. CONCLUSION Our report suggests that unusual mood disorder and language disorder of aged patients might indicate the AOP occlusion, and cerebral imaging of magnetic resonance imaging (better with magnetic resonance angiography) should be performed to establish the diagnosis of AOP occlusion. The fast and accurate diagnosis of stroke because of AOP occlusion could best benefit the patients.
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Affiliation(s)
| | | | - Bin Cui
- Medical Imaging, Aerospace Center Hospital, Beijing, China
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11
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Benke T, Bodner T, Wiesen D, Karnath HO. The Amnestic Syndrome of Posterior Cerebral Artery Infarction. Eur J Neurol 2022; 29:2987-2995. [PMID: 35708171 PMCID: PMC9541518 DOI: 10.1111/ene.15449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Little is known about the character and underlying lesions of ischemic amnesia. We therefore studied episodic memory functions and brain lesions in 84 patients with acute ischemic infarcts in the supply territory of the posterior cerebral artery (PCA). We also aimed to learn how the neural memory systems are organized. METHODS Standard neuropsychological tests were used to assess verbal and figural memory. Patients were split in memory-impaired and memory-intact. Lesions were demarcated, normalized and anatomically labeled, using standard mapping procedures. RESULTS Of the 84 patients more than 80% had an amnestic syndrome, mostly with combined, less often with figural or verbal memory impairment. Amnesia in subjects with left hemispheric lesions was more frequent and more severe, with significantly lower scores on the verbal memory test. Normal performance or figural amnesia were prevalent after right hemispheric lesions. However, no amnesia subtype was strictly tied to left- or right-sided brain damage. Hippocampal and thalamic lesions were common, but 30% of lesions were extrahippocampal located in the ventral occipito-temporal cortex and long occipital white matter tracts. Most amnestic-patients lacked awareness for their memory impairment. CONCLUSIONS Memory impairment is a key clinical manifestation of acute PCA stroke. Amnesia is more frequent and more severe after left stroke, suggesting a left hemisphere dominance of the two memory systems. Domain specific memory appears not strictly lateralized, since deficits in verbal and figural memory were found after lesions of both sides. Extrahippocampal lesions may also cause memory impairment.
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Affiliation(s)
- Thomas Benke
- Clinic of Neurology, Medical University Innsbruck, Austria
| | - Thomas Bodner
- Clinic of Neurology, Medical University Innsbruck, Austria
| | - Daniel Wiesen
- Division of Neuropsychology, Center of Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Hans-Otto Karnath
- University of Tübingen, Departments of Cognitive and General Neurology, Tübingen, Germany
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12
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Tavazzi E, Bergsland N, Pirastru A, Pelizzari L, Cazzoli M, Saibene FL, Navarro JS, Farina E, Comanducci A, Cecconi P, Baglio F. Brain plasticity after rehabilitation in a severe case of artery of Percheron stroke assessed with multimodal MR imaging. Neurocase 2022; 28:194-198. [PMID: 35465838 DOI: 10.1080/13554794.2022.2062249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Artery of Percheron (AOP) stroke is a rare event. We describe an AOP stroke involving both thalami and the midbrain, resulting in a multifunctional clinical impairment. Intensive inpatient multidisciplinary rehabilitation favored the recovery of motor deficits, together with the improvement of cognitive dysfunctions. MRI assessment in the chronic post-stroke phase showed structural and functional reorganization in response to the extended thalamic tissue damage and absence of revascularization. Thalamo-cortical networks involving frontal and prefrontal regions, as well as parietal areas were disrupted, whereas increased functional thalamo-occipital connectivity was found. This report sheds light on brain reorganization following AOP stroke after rehabilitation..
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Affiliation(s)
- E Tavazzi
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy.,Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States
| | - N Bergsland
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy.,Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, United States
| | - A Pirastru
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - L Pelizzari
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - M Cazzoli
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - F L Saibene
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - J S Navarro
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - E Farina
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - A Comanducci
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - P Cecconi
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - F Baglio
- IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
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13
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Flowers J, Gandhi S, Guduguntla L, Yang A, Moudgil S. Artery of Percheron Strokes: Three Cases in Three Months. Cureus 2022; 14:e21688. [PMID: 35237483 PMCID: PMC8882330 DOI: 10.7759/cureus.21688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
The artery of Percheron (AOP) is a rare variant of thalamic vasculature and is a single dominant thalamoperforating artery supplying bilateral paramedian thalamic territories. Occlusion of the AOP results in a characteristic pattern of bilateral paramedian thalamic infarcts and is estimated to represent between 0.1%-0.3% of all ischemic strokes and 4% to 35% of all thalamic strokes. Four distinct ischemic patterns of AOP infarcts have been identified: bilateral paramedian thalamic region with midbrain (43%), bilateral paramedian thalamic without midbrain (38%), bilateral paramedian thalamic with anterior thalamus and midbrain involvement (14%), and bilateral paramedian thalamic with anterior thalamus without midbrain involvement (5%). Despite our knowledge of the characteristic radiologic features of an AOP stroke, the true incidence of AOP strokes is challenging to estimate due to non-specific clinical symptoms and subtle findings on computed tomography (CT) and/or magnetic resonance imaging (MRI). Here, we present a case series of three patients seen within a 3-month span at one community hospital seen by one single neurologist with confirmed AOP stroke by radiologic imaging. The frequency of these cases suggests that the incidence of AOP infarctions may be higher than previously estimated and instead are underreported due to broad differential on clinical and imaging presentation.
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14
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Macedo M, Reis D, Cerullo G, Florêncio A, Frias C, Aleluia L, Drago J, Nzwalo H, Fidalgo AP. Stroke due to Percheron Artery Occlusion: Description of a Consecutive Case Series from Southern Portugal. J Neurosci Rural Pract 2022; 13:151-154. [PMID: 35110938 PMCID: PMC8803518 DOI: 10.1055/s-0041-1741485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The artery of Percheron (AOP) is an abnormal variant of the arterial supply of the thalamus. Stroke caused by AOP occlusion is seldom reported. AOP leads to bilateral thalamic and rostral midbrain infarct presenting with unspecific manifestations. There are few descriptions of case series of stroke caused by AOP. We sought to review the clinicoradiological characteristics of AOP infarction from Algarve, Southern Portugal. Eight consecutive cases were retrospectively identified by searching the electronic clinical charts, as well as the stroke Unit database (2015–2020). Sociodemographic (age and gender) and clinicoradiological characteristics (etiological classification, admission severity, manifestations, and short- and long-term prognoses) were retrieved. The corresponding frequency of AOP infarction was 0.17% (95% confidence interval: 0.05–0.28). The mean age was 67.1 (range: 60–80) years. The range of stroke severity evaluated assessed by the National Institute of Health Stroke Scale ranged from 5 to 23 (median = 7.5). None of the patients receive acute ischemic stroke reperfusion treatment. AOP patterns were isolated bilateral paramedian thalamic (
n
= 2), bilateral paramedian and anterior thalamic (
n
= 2), and bilateral paramedian thalamic with rostral midbrain (
n
= 4). Two patients (20%) died on the short term (30 days). At hospital discharge, six patients had functional disability of ≤2 on the modified Rankin scale. In the follow-up at 6 months, half (
n
= 3) of the survivors had persistent hypersomnia and two had vascular dementia. Stroke from AOP presents with variable clinical and radiological presentations and patients do not receive alteplase. The short-term survivor and the long-term functional independency can be compromised after AOS infarct.
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Affiliation(s)
- Miguel Macedo
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
- Department of Physical Medicine and Rehabilitation, University Hospital Center of Algarve, Faro, Portugal
| | - Diana Reis
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - Giovanni Cerullo
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - André Florêncio
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - Catarina Frias
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - Leonor Aleluia
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - José Drago
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
| | - Hipólito Nzwalo
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
- Department of Biomedical Sciences and Medicine, University of the Algarve, Faro, Portugal
| | - Ana P. Fidalgo
- Department of Internal Medicine, Stroke Unit, University Hospital Center of Algarve, Faro, Portugal
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15
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Rangus I, Fritsch M, Endres M, Udke B, Nolte CH. Frequency and phenotype of thalamic aphasia. J Neurol 2022; 269:368-376. [PMID: 34100990 PMCID: PMC8739316 DOI: 10.1007/s00415-021-10640-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aphasia is a recognized presenting symptom of thalamic lesions. Little is known regarding its frequency and phenotype. We examined the frequency of thalamic aphasia following Isolated Acute unilateral ischemic Lesions in the Thalamus (IALT) with respect to lesion location. Furthermore, we characterized thalamic aphasia according to affected language domains and severity. METHODS Fifty-two patients with IALT were analyzed [44% female, median age: 73 years (IQR: 60-79)]. Lesion location was determined using 3-Tesla magnetic resonance imaging and categorized as anterior, posterior, paramedian or inferolateral. Standardized language assessment was performed using the validated Aphasia checklist (ACL) directly after symptom onset. Aphasia was defined as an ACL sum score of < 135 (range: 0-148). RESULTS Of 52 patients, 23 (44%) fulfilled the ACL diagnostic criteria for aphasia, including nearly all lesion locations and both sides. The average ACL sum score was 132 ± 11 (range: 98-147). Aphasia was characterized by deficits within domains of complex understanding of speech and verbal fluency. Patients with left anterior IALT were most severely affected, having significantly lower ACL scores than all other patients (117 ± 13 vs. 135 ± 8; p < 0.001). In particular, aphasia in patients with left anterior IALT was characterized by significantly worse performance in the rating of verbal communication, verbal fluency, and naming (all p ≤ 0.001). CONCLUSION Aphasia occurs in almost half of patients with focal thalamic lesions. Thalamic aphasia is not confined to one predefined thalamic lesion location, but language deficits are particularly pronounced in patients with left anterior IALT presenting with a distinct pattern.
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Affiliation(s)
- Ida Rangus
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Merve Fritsch
- Department of Psychiatry, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Birgit Udke
- Department of Audiology and Phoniatrics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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16
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Özek MM, Bozkurt B. Surgical Approach to Thalamic Tumors. Adv Tech Stand Neurosurg 2022; 45:177-198. [PMID: 35976450 DOI: 10.1007/978-3-030-99166-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thalamic tumors are deep-seated lesions. Recent improvements in therapeutic approaches and surgical techniques have allowed a more accurate approach to these lesions and a reduction in morbidity and mortality. In this article, the various surgical approaches for the resection of thalamic tumors are described. Each of these approaches has its own indications and risk of complications. Resection of thalamic tumors needs specific anatomical knowledge, especially the vascular anatomy of the region and the thalamic peduncles.
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Affiliation(s)
- M Memet Özek
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Acıbadem University, School of Medicine, Istanbul, Turkey.
| | - Baran Bozkurt
- Neuroanatomy Laboratory at Department of Neurosurgery, Acıbadem University, School of Medicine, Istanbul, Turkey
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17
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Fritsch M, Rangus I, Nolte CH. Thalamic Aphasia: a Review. Curr Neurol Neurosci Rep 2022; 22:855-865. [PMID: 36383308 PMCID: PMC9750901 DOI: 10.1007/s11910-022-01242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Thalamic aphasia is a rare language disorder resulting from lesions to the thalamus. While most patients exhibit mild symptoms with a predominance of lexical-semantic difficulties, variations in phenotype have been described. Overall, the exact mechanisms of thalamic aphasia await empirical research. The article reviews recent findings regarding phenotypes and possible underlying mechanisms of thalamic aphasia. RECENT FINDINGS Variations in phenotype of thalamic aphasia may be related to different lesion locations. Overall, the thalamus' role in language is thought to be due to its involvement in cortico-thalamic language networks with lesioning of certain nuclei resulting in the diachisis of otherwise interconnected areas. Its possible monitoring function in such a network might be due to its different cellular firing modes. However, no specific evidence has been collected to date. While recent findings show a more distinct understanding of thalamic aphasia phenotypes and possible underlying mechanisms, further research is needed. Additionally, as standard language testing might oftentimes not pick up on its subtle symptoms, thalamic aphasia might be underdiagnosed.
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Affiliation(s)
- Merve Fritsch
- grid.6363.00000 0001 2218 4662Department of Psychiatry and Psychotherapy, Charité—Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Ida Rangus
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany ,grid.6363.00000 0001 2218 4662Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany ,grid.6363.00000 0001 2218 4662Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
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18
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Abstract
PURPOSE OF REVIEW Subcortical structures have long been thought to play a role in language processing. Increasingly spirited debates on language studies, arising from as early as the nineteenth century, grew remarkably sophisticated as the years pass. In the context of non-thalamic aphasia, a few theoretical frameworks have been laid out. The disconnection hypothesis postulates that basal ganglia insults result in aphasia due to a rupture of connectivity between Broca and Wernicke's areas. A second viewpoint conjectures that the basal ganglia would more directly partake in language processing, and a third stream proclaims that aphasia would stem from cortical deafferentation. On the other hand, thalamic aphasia is more predominantly deemed as a resultant of diaschisis. This article reviews the above topics with recent findings on deep brain stimulation, neurophysiology, and aphasiology. RECENT FINDINGS The more recent approach conceptualizes non-thalamic aphasias as the offspring of unpredictable cortical hypoperfusion. Regarding the thalamus, there is mounting evidence now pointing to leading contributions of the pulvinar/lateral posterior nucleus and the anterior/ventral anterior thalamus to language disturbances. While the former appears to relate to lexical-semantic indiscrimination, the latter seems to bring about a severe breakdown in word selection and/or spontaneous top-down lexical-semantic operations. The characterization of subcortical aphasias and the role of the basal ganglia and thalamus in language processing continues to pose a challenge. Neuroimaging studies have pointed a path forward, and we believe that more recent methods such as tractography and connectivity studies will significantly expand our knowledge in this particular area of aphasiology.
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19
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Schaller-Paule MA, Oeckel AM, Schüre JR, Keil F, Hattingen E, Foerch C, Rauch M. Isolated thalamic stroke - analysis of clinical characteristics and asymmetry of lesion distribution in a retrospective cohort study. Neurol Res Pract 2021; 3:49. [PMID: 34511109 PMCID: PMC8436465 DOI: 10.1186/s42466-021-00148-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022] Open
Abstract
Background More patients with left-hemispheric than right-hemispheric strokes are admitted to hospitals. This is due to the easier recognition of cortical symptoms of the dominant-hemisphere. The thalamus constitutes a “micro-model” of the brain cortex with structure-function relationships known to be asymmetric, especially for language, memory, and visuo-spatial neurocognitive functions. The goal of this study was to characterize clinical symptoms and lesion distribution patterns of patients with acute isolated thalamic stroke (ITS) and to evaluate whether left-sided lesions are overrepresented in the hospital. Methods We performed a radiological database search including all brain scans performed in the Center of Neurology and Neurosurgery of the University Hospital Frankfurt between 2010 and 2019. A total of 5733 patients presenting with acute ischemic stroke were screened for ITS. Based on the MRI data, a lesion-overlap map was then generated to visualize the ITS lesion distribution. Results Fifty-eight patients with unilateral ITS were identified. A majority of 38 patients (65.5%) showed left-sided ITS, whereas only 20 patients (34.5%) had right-sided ITS (p = 0.012). A particular difference was found for ITS lesions in the anterior thalamus of the anterolateral (n = 10) and anteromedian (n = 3) vascular territory, which were located in the left thalamus in 85% of patients (p = 0.011). No distribution difference was found for ITS lesions in the inferomedial (n = 7), central (n = 8), inferolateral (n = 23) and posterior (n = 7) vascular territories. The neuropsychological symptoms of thalamic aphasia (n = 8), neurocognitive impairment (n = 6), behavioral changes (n = 2), neglect (n = 2) and memory deficits (n = 3) were described predominantly in patients with left-sided ITS (p < 0.01). In contrast, other stroke symptoms (e.g., sensorimotor hemi-syndromes) did not reveal a side preponderance. Conclusions The better recognizability of left anterior compared to right anterior thalamic stroke symptoms may have an impact on the frequency in which ITS patients are admitted to the hospital. Clinical characteristics of right anterior thalamic stroke should therefore be further investigated, and diagnostic instruments towards their detection be identified.
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Affiliation(s)
- Martin A Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2 - 16, D-60528, Frankfurt am Main, Germany.
| | - Ariane Martinez Oeckel
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2 - 16, D-60528, Frankfurt am Main, Germany
| | - Jan-Rüdiger Schüre
- Brain Imaging Center, Goethe-University, Frankfurt am Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Fee Keil
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2 - 16, D-60528, Frankfurt am Main, Germany
| | - Maximilian Rauch
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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20
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Aaron S, Mary J, Arthur A, Nidugala SK, Mani S, Prabakhar AT, Sivadasan A, Mathew V, Alexander M. Paradoxical Emboli to Artery of Percehron in Hereditary Haemorrhagic Telangiectasia. Neurol India 2021; 69:198-200. [PMID: 33642302 DOI: 10.4103/0028-3886.310068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sanjith Aaron
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - John Mary
- Department of ENT, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anupriya Arthur
- Department of Ophthalmology, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | | | - Sunithi Mani
- Department of Radiology, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A T Prabakhar
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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21
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Kheiralla O, Alghamdi S, Aljondi R, Tajaldeen A, Bakheet A. Artery of Percheron Infarction: A Characteristic Pattern of Ischemia and Variable Clinical Presentation: A Literature Review. Curr Med Imaging 2021; 17:669-674. [PMID: 33256583 DOI: 10.2174/1573405616666201130095801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 11/22/2022]
Abstract
The Artery of Percheron (AOP) is an uncommon anatomic variant that provides arterial supply to the paramedian region of the thalami and bilaterally to the rostral part of the midbrain; it is a solitary arterial trunk that branches from a proximal segment of the posterior cerebral artery (PCA). Although AOP infarction results in a characteristic pattern of ischemia-namely bilateral paramedian thalamic infarct with or without midbrain involvement-it may cause diagnostic difficulties due to the variety of its clinical presentations and wide differentials, as well as its small diameter and the difficulty of obtaining visualization through diagnostic imaging. Early neuroimaging of AOP infarction and correct diagnosis are mandatory for early initiation of the appropriate treatment and better patient outcomes. In this study, we discuss imaging the patterns of AOP infarction and its differentials and clinical presentation.
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Affiliation(s)
- Osama Kheiralla
- Radiological Sciences Department, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Salem Alghamdi
- Department of Applied Radiologic Technology, College of Applied Medical Sciences, University of Jeddah, Jeddah, Saudi Arabia
| | - Rowa Aljondi
- Department of Applied Radiologic Technology, College of Applied Medical Sciences, University of Jeddah, Jeddah, Saudi Arabia
| | - Abdulrahman Tajaldeen
- Radiological Sciences Department, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Adel Bakheet
- Radiological Sciences Department, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
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22
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Dogan SN, Cengel F, Bayrak AH, Yazgu R. Topographic evaluation of bithalamic infarcts: Are these due to occlusion of the artery of Percheron? J Clin Neurosci 2021; 90:99-104. [PMID: 34275589 DOI: 10.1016/j.jocn.2021.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/06/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Sebahat Nacar Dogan
- Gaziosmanpaşa Training and Research Hospital, Department of Radiology, Istanbul, Turkey.
| | - Ferhat Cengel
- Gaziosmanpaşa Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | | | - Rıdvan Yazgu
- Gaziosmanpaşa Training and Research Hospital, Department of Neurology, Istanbul, Turkey
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23
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Quetsch M, Nagiah S, Hedger S. Stroke masquerading as cardiac arrest: the artery of Percheron. BMJ Case Rep 2021; 14:14/1/e238681. [PMID: 33431467 PMCID: PMC7802725 DOI: 10.1136/bcr-2020-238681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The artery of Percheron (AOP) is a rare arterial variant of the thalamic blood supply. Due to the densely packed collection of nuclei it supplies, an infarction of the AOP can be devastating. Here we highlight a patient who had an AOP stroke in the community, which was initially managed as cardiac arrest. AOP strokes most often present with vague symptoms such as reduced conscious level, cognitive changes and confusion without obvious focal neurology, and therefore are often missed at the initial clinical assessment. This case highlights the importance of recognising an AOP stroke as a cause of otherwise unexplained altered consciousness level and the use of MRI early in the diagnostic work-up.
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Affiliation(s)
- Megan Quetsch
- General Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sureshkumar Nagiah
- General Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Stephen Hedger
- General Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Kheiralla OAM. Artery of Percheron infarction a rare anatomical variant and a diagnostic challenge: Case report. Radiol Case Rep 2020; 16:22-29. [PMID: 33163128 PMCID: PMC7599376 DOI: 10.1016/j.radcr.2020.10.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/17/2020] [Accepted: 10/17/2020] [Indexed: 11/26/2022] Open
Abstract
The Artery of Percheron (AOP) is an uncommon anatomic variant that provides arterial supply to the paramedian region of the thalami and bilaterally to the rostral part of the midbrain; it is a solitary arterial trunk that branches from a proximal segment of the posterior cerebral artery (PCA). Although AOP infarction results in a characteristic pattern of ischemia, namely bilateral paramedian thalamic infarct with or without midbrain involvement, it may cause diagnostic difficulties due to the variety of its clinical presentations and wide differentials, as well as its small diameter and the difficulty of obtaining visualization through diagnostic imaging. Early neuroimaging of AOP infarction and correct diagnosis are mandatory for early initiation of the appropriate treatment and better patient outcomes. This study discusses the imaging patterns and imaging differentials of AOP infarction and its clinical presentation. A 55-year-old man presented to the emergency department unconscious with Glasgow Coma Scale score of 4. Pupillary light reflex on both eyes was poorly reactive with dilatated right pupil. The patient flexed his arm and extended his leg on painful stimulus. Laboratory tests and electrocardiogram were unremarkable. Emergency cerebral CT scan and transcranial Doppler ultrasound were normal. He gradually regained consciousness with residual somnolence, ptosis, and vertical gaze palsy. Second CT scan showed bilateral paramedian thalamic areas of hypodensity, CT angiography (CTA) was unremarkable. MRI showed bilateral high-signal intensity on paramedian thalami fast spin echo T2, FLAIR, and diffusion-weighted sequences, low signal on apparent diffusion coefficient sequence. MR angiography (MRA) revealed an abnormal tiny vessel arising from the P1 segment of the left posterior cerebral artery. Imaging findings were consistent with AOP infarction. Aspirin was started, 4 hours after admission the patient regained consciousness, and gradually improved on the following days till he was discharged on the 15th day, with mild neurologic deficit. AOP must be considered whenever paramedian thalamic infarction is noted in neuroimaging. The difficulty in visualizing the AOP using diagnostic imaging is due to its small diameter, leading to the limited abilities of MRA and CTA to diagnose AOP infarction. An absence of evidence of AOP infarction in MRA or even CTA does not exclude its diagnosis. Good knowledge of the imaging characteristics of AOP infarction will help in early diagnosis and the achievement of good patient outcomes.
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Ranasinghe KMIU, Herath HMMTB, Dissanayake D, Seneviratne M. Artery of Percheron infarction presenting as nuclear third nerve palsy and transient loss of consciousness: a case report. BMC Neurol 2020; 20:320. [PMID: 32859166 PMCID: PMC7453528 DOI: 10.1186/s12883-020-01889-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background Thalamic blood supply consists of four major vascular territories. Out of them paramedian arteries supply ipsilateral paramedian thalami and occasionally rostral mid brain. Rarely both paramedian arteries arise from a common trunk that arise from P1 segment of one sided posterior cerebral artery (PCA). This is usually due to hypoplastic or absent other P1 and this common trunk is termed Artery of Percheron (AOP). Its prevalence is in the range of 7–11% among the general population and AOP infarcts account in an average of 0.4–0.5% of ischemic strokes. Clinical presentation of AOP infarction is characterized by impaired arousal and memory, language impairment and vertical gaze palsy. It also can present with cerebellar signs, hemi paresis and hemi sensory loss. We herein present a case of AOP infarction presenting as transient loss of consciousness and nuclear third nerve palsy. Case presentation A 51 year old previously healthy male, was brought to us, with a Glasgow coma scale (GCS) of 7/15. GCS improved to 11/15 by the next day, however he had a persisting expressive aphasia. Right sided nuclear third nerve palsy was apparent with the improvement of GCS. He did not have pyramidal or cerebellar signs. Thrombolysis was not offered as the therapeutic window was exceeded by the time of diagnosis. Diagnosis was made using magnetic resonance imaging (MRI) that was done after the initial normal non-contrast computer tomography (NCCT) brain. He was enrolled in stroke rehabilitation. Aspirin and atorvastatin was started for the secondary prevention of stroke. He achieved independency of advanced daily living by 1 month, however could not achieve full recovery to be employed as a taxi driver. Conclusions Because of the rarity and varied clinical presentation with altered levels of consciousness, AOP infarcts are easily overlooked as a stroke leading to delayed diagnosis. Timely diagnosis can prevent unnecessary investigations and the patient will be benefitted by early revascularization. As it is seldom reported, case reports remain a valuable source of improving awareness among physicians about this clinical entity.
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Cox M, Rodriguez P, Mohan S, Sedora-Roman NI, Pukenas B, Choudhri O, Kurtz RM. Tentorial Dural Arteriovenous Fistulas as a Cause of Thalamic Edema: 2 Cases of an Important Differential Diagnosis to Consider. Neurohospitalist 2020; 11:33-39. [PMID: 33868554 DOI: 10.1177/1941874420944333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The differential diagnosis for bilateral thalamic edema is extensive and includes vascular, neoplastic, metabolic, and infectious causes. Of the vascular causes of thalamic edema, arterial and venous infarctions are well-documented, but dural arteriovenous fistulas (dAVFs) are a relatively uncommon and widely underrecognized cause of thalamic edema. Dural AVFs are notoriously difficult to diagnose clinically, especially in the absence of hemorrhage, and cross-sectional imaging findings can be subtle. This can result in a delayed diagnosis, and occasionally, an invasive biopsy for further clarification of a purely vascular disease. In this review, we detail our experience with the imaging diagnosis of dAVF as a cause of thalamic edema and present a short differential of other vascular causes.
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Affiliation(s)
- Mougnyan Cox
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Pavel Rodriguez
- Neurointerventional Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Suyash Mohan
- Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Neda I Sedora-Roman
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Omar Choudhri
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Kurtz
- Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Bordes S, Werner C, Mathkour M, McCormack E, Iwanaga J, Loukas M, Lammle M, Dumont AS, Tubbs RS. Arterial Supply of the Thalamus: A Comprehensive Review. World Neurosurg 2020; 137:310-318. [DOI: 10.1016/j.wneu.2020.01.237] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 12/14/2022]
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Amtul Z, Frías C, Randhawa J, Hill DJ, Arany EJ. The spatial cerebral damage caused by larger infarct and β-amyloid toxicity is driven by the anatomical/functional connectivity. J Comp Neurol 2020; 528:48-60. [PMID: 31265125 DOI: 10.1002/cne.24738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/04/2019] [Accepted: 06/18/2019] [Indexed: 11/07/2022]
Abstract
Large cerebral infarctions are major predictors of death and severe disability from stroke. Conversely, data concerning these types of infarctions and the affected adjacent brain circuits are scarce. It remains to be determined if the co-morbid concurrence of large infarct and β-amyloid (Aβ) toxicity can precipitate the early development of dementia. Here, we described a dose-dependent effect of a unilateral striatal injection of vasoconstrictive endothelin-1 (ET-1) along with Aβ toxicity on CNS pathogenesis; driven by the anatomical and functional networks within a brain circuit. After 21 days of treatment, a high dose (60 pmol) of ET-1 (E60) alone caused the greatest increase in neuroinflammation, mainly in the ipsilateral striatum and distant regions with synaptic links to the striatal lesion such as white matter (subcortical white matter, corpus callosum, internal capsule, anterior commissure), gray matter (globus pallidus, thalamus), and cortices (cingulate, motor, somatosensory, entorhinal). The combined E60 + Aβ treatment also extended perturbation in the contralateral hemisphere of these rats, such as increased deposition of amyloid precursor protein fragments associated with the appearance of degenerating cells and the leakage of laminin from the basement membrane across a compromised blood-brain barrier. However, the cerebral damage induced by the 6 pmol ET-1 (E6), Aβ and E6 + Aβ rats was not detrimental enough to injure the complete network. The appreciation of the causal interactions among distinct anatomical units in the brain after ischemia and Aβ toxicity will help in the design of effective and alternative therapeutics that may disassociate the synergistic or additive association between the infarcts and Aβ toxicity.
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Affiliation(s)
- Zareen Amtul
- Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, Canada
| | - Carmen Frías
- Department of Anatomy and Cell Biology, University of Western Ontario, London, Ontario, Canada
| | - Jasmine Randhawa
- Department of Biology, University of Western Ontario, London, Ontario, Canada
| | - David J Hill
- Department of Medicine, Physiology, and Pharmacology, and Pediatrics, University of Western Ontario, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Edith J Arany
- Department of Pathology and Laboratory Medicine, University of Western Ontario, London, Ontario, Canada
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Griffin AS, Mariano R, Hauck SK, Hauck EF. Inferolateral thalamic ischemia secondary to PCA P2 perforator occlusion mimics MCA stroke syndrome. Neurosurg Rev 2019; 43:339-342. [PMID: 31709467 DOI: 10.1007/s10143-019-01211-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/11/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
Paramedian thalamic strokes following occlusion of the posterior medial (paramedian) thalamic perforators have been previously described in great detail. However, the stroke syndrome associated with occlusion of posterior lateral (inferolateral) thalamic perforators is less commonly known. We present an illustrative case of an inferolateral thalamic perforator stroke mimicking a middle cerebral artery (MCA) syndrome and provide a review of the literature. A 62-year-old male presented with dysarthria, contralateral hemisensory loss, and contralateral weakness, concerning for possible MCA stroke. However, close examination revealed the hemiparesis to be ataxic in nature. Imaging revealed a left PCA P2 segment occlusion and lacunar infarction of the ventral lateral (VL) and ventral posterior (VP) thalamus, the main thalamic destination of cerebellar and sensory pathways. The case is unique because the P1 segment and posterior communicating artery (Pcom) remained patent, resulting in selective occlusion of only the posterior lateral (inferolateral) thalamic perforators at the P2 level. Acute loss of the posterior lateral (inferolateral) thalamic perforators at the proximal P2 segment results in a ventral lateral and ventral posterior thalamic stroke characterized by contralateral hemisensory loss, contralateral ataxic hemiparesis, and dysarthria. It is important to recognize the inferolateral thalamic stroke syndrome, as it may be mistaken clinically for an MCA occlusion. The benefit of mechanical thrombectomy for this type of stroke is not well established and should be considered carefully.
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Affiliation(s)
- Andrew S Griffin
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA.
| | - Rowena Mariano
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA
| | - Soeren K Hauck
- Department of Neurosurgery, University of Hannover, Hanover, Germany
| | - Erik F Hauck
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA
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Ali A, Mellor S, Lapsia S. Artery of Percheron infarction. Br J Hosp Med (Lond) 2019; 80:412-413. [PMID: 31283403 DOI: 10.12968/hmed.2019.80.7.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ahmed Ali
- Radiology Registrar, Department of Radiology, Royal Blackburn Hospital, Blackburn BB2 3HH
| | - Stuart Mellor
- Consultant Radiologist, Department of Radiology, Royal Blackburn Hospital, Blackburn
| | - Snehal Lapsia
- Consultant Radiologist, Department of Radiology, Royal Blackburn Hospital, Blackburn
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Acute Onset of Hypersomnolence and Aphasia Secondary to an Artery of Percheron Infarct and a Proposed Emergency Room Evaluation. Case Rep Emerg Med 2019; 2019:1260865. [PMID: 31093385 PMCID: PMC6476073 DOI: 10.1155/2019/1260865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/17/2022] Open
Abstract
Artery of Percheron (AOP) is a rare anatomical variant, which supplies bilateral paramedian thalami and the rostral mesencephalon via a single dominant thalamic perforating artery arising from the P1 segment of a posterior cerebral artery. AOP infarcts can present with a plethora of neurological symptoms: altered mental status, memory impairment, hypersomnolence, coma, aphasia, and vertical gaze palsy. Given the lack of classic stroke signs, majority of AOP infarcts are not diagnosed in the emergency setting. Timely diagnosis of an acute bilateral thalamic infarct can be challenging, and this case report highlights the uncommon neurological presentation of AOP infarction. The therapeutic time window to administer IV tPA can be missed due to this delay in diagnosis, resulting in poor clinical outcomes. To initiate appropriate acute ischemic stroke management, we propose a comprehensive radiological evaluation in the emergency room for patients with a high suspicion of an AOP infarction.
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Godfrey M, Gillis MM, Khurana D, Poletto E, Tarazi RA. Neuropsychological outcome following thalamic stroke in adolescence: an identical twin comparison. Clin Neuropsychol 2018; 33:905-927. [DOI: 10.1080/13854046.2018.1533997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Mary Godfrey
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | | | - Divya Khurana
- St. Christopher’s Hospital for Children, Philadelphia, PA, USA
- Department of Pediatrics, Drexel University, Philadelphia, PA, USA
| | - Erica Poletto
- St. Christopher’s Hospital for Children, Philadelphia, PA, USA
- Department of Pediatrics, Drexel University, Philadelphia, PA, USA
- Department of Radiologic Sciences, Drexel University, Philadelphia, PA, USA
| | - Reem A. Tarazi
- St. Christopher’s Hospital for Children, Philadelphia, PA, USA
- Department of Psychiatry, Drexel University, Philadelphia, PA, USA
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33
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Spatial Dynamics of Vascular and Biochemical Injury in Rat Hippocampus Following Striatal Injury and Aβ Toxicity. Mol Neurobiol 2018; 56:2714-2727. [DOI: 10.1007/s12035-018-1225-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 07/05/2018] [Indexed: 01/09/2023]
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34
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Shabbir SH, Nadeem F, Labovitz D. Anteromedial thalamic infarct: a rare presentation. BMJ Case Rep 2018; 2018:bcr-2017-223404. [PMID: 29724871 DOI: 10.1136/bcr-2017-223404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a rare presentation of an anteromedial thalamic infarct in a 50-year-old woman with acute onset left eye ptosis, vertical gaze paresis and confusion. MRI identified an acute left anteromedial thalamic infarct with a severe left P1 stenosis. Thalamic infarcts are associated with marked neurobehavioural disturbances with dominant thalamic lesions causing language deficits, verbal perseveration, memory disturbances, abulia and disorientation. Ocular movement deficits can also be present and typically accompany paramedian lesions. Rarely, patients can develop an ipsilateral ptosis. We discuss these symptoms and review the literature.
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Affiliation(s)
- Syed H Shabbir
- Department of Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Faryal Nadeem
- Department of Medicine, Capital Health Regional Medical Center, Trenton, New Jersey, USA
| | - Daniel Labovitz
- Department of Neurology, Montefiore Hospital and Medical Center, Bronx, New York, USA
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Li S, Kumar Y, Gupta N, Abdelbaki A, Sahwney H, Kumar A, Mangla M, Mangla R. Clinical and Neuroimaging Findings in Thalamic Territory Infarctions: A Review. J Neuroimaging 2018; 28:343-349. [DOI: 10.1111/jon.12503] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/18/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Shuo Li
- Department of Radiology; Yale New Haven Health Bridgeport Hospital; Bridgeport CT
| | - Yogesh Kumar
- Department of Radiology; Columbia University at Bassett Healthcare; Cooperstown NY
| | - Nishant Gupta
- Department of Radiology; Columbia University Medical Center; New York NY
| | - Ahmed Abdelbaki
- Department of Radiology; Yale New Haven Health Bridgeport Hospital; Bridgeport CT
| | - Harpreet Sahwney
- Department of Radiology; Yale New Haven Health Bridgeport Hospital; Bridgeport CT
| | - Anil Kumar
- Division of Neurology; Department of Internal Medicine; Great Plains Health; North Platte NE
| | - Manisha Mangla
- Department of Public Health and Preventive Medicine; State University of New York (SUNY) Upstate Medical University; Syracuse NY
| | - Rajiv Mangla
- Department of Radiology; State University of New York (SUNY) Upstate Medical University; Syracuse NY
- Department of Radiology; University of Rochester; Rochester NY
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Stamm BJ, Lineback CM, Skolarus LE, Morgenstern LB, Shah GV. Artery of Percheron Infarct: 12 Cases and Their Complex Clinical Courses. Neurohospitalist 2017; 8:141-145. [PMID: 29977445 DOI: 10.1177/1941874417748543] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Strokes involving the artery of Percheron (AOP), an anatomic variant of thalamic vascular supply, are rare. Little is known about the inpatient hospital course for these patients. We retrospectively identified consecutive patients with AOP in their medical charts from a university-based tertiary care hospital from January 1, 2000, to August 15, 2017. A chart review identified demographics, transfer status, in-hospital versus community onset of stroke, emergency medical services (EMS) use, presenting signs/symptoms, time to radiologic diagnosis (from time of presentation to tertiary care hospital or from time of initial symptom onset in an already hospitalized patient), tissue plasminogen activator (tPA) use, intensive care unit (ICU) stays, intubation, length of stay (LOS), and discharge location. After radiologic inclusion/exclusion criteria were applied, 12 patients were included in the study. There were 7 men and 5 women, and the mean age (SD) was 68 (15). Seven were transfers, and 4 had an in-hospital stroke. Of the 8 community-onset strokes, 7 utilized EMS. Mental status changes occurred in 11 of 12 and ocular disturbances in all patients. Time to radiologic diagnosis averaged 1.9 (median = 1.1) days. One patient received tPA. Eight received care in the ICU. Four were intubated. Average LOS was 8.3 days. Four were discharged home, 3 entered inpatient rehabilitation facilities, and 5 entered skilled nursing facilities. In-hospital stroke status further complicates the already challenging diagnosis of AOP infarct, and clinicians must maintain a high suspicion for this rare stroke in order to quickly diagnose and intervene.
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Affiliation(s)
- Brian J Stamm
- Medical School, University of Michigan, Ann Arbor, MI, USA
| | | | - Lesli E Skolarus
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - Gaurang V Shah
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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Mole J, Winegardner J, Malley D, Fish J. Time perception impairment following thalamic stroke: A case study. Neuropsychol Rehabil 2017; 28:208-222. [PMID: 29108479 DOI: 10.1080/09602011.2017.1383273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Impaired time perception is considered to be a relatively unusual and poorly understood consequence of brain injury. This paper presents a case study of altered time perception in JB, a 50-year-old woman who in 2011 had a small thalamic stroke affecting the right anteromedian region. We report on her subjective experience and present results from studies of retrospective timing (i.e., estimating how much time has passed and the clock time) and prospective timing (i.e., producing and reproducing intervals). The results showed that relative to neurologically healthy and brain-injured controls, JB had impaired retrospective timing and impaired prospective time reproduction. However, her prospective time production did not differ significantly from either of the control groups. We interpret this to mean that JB's essential timing functions are intact, and that rather, her time perception impairment stems from a problem in anterograde memory for time intervals. Further, we argue that unlike other cognitive domains, time perception alteration is neither anticipated nor evaluated in most patients, yet these impairments can have a remarkably serious impact on daily life. We encourage further investigation of this topic.
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Affiliation(s)
- Joe Mole
- a Oliver Zangwill Centre for Neuropsychological Rehabilitation , Princess of Wales Hospital , Ely , United Kingdom
| | - Jill Winegardner
- a Oliver Zangwill Centre for Neuropsychological Rehabilitation , Princess of Wales Hospital , Ely , United Kingdom
| | - Donna Malley
- a Oliver Zangwill Centre for Neuropsychological Rehabilitation , Princess of Wales Hospital , Ely , United Kingdom
| | - Jessica Fish
- a Oliver Zangwill Centre for Neuropsychological Rehabilitation , Princess of Wales Hospital , Ely , United Kingdom
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38
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Ko JH, Kim YJ. Endovascular strategies for treatment of posterior communicating artery aneurysm according to angiographic architecture: Preservation vs. sacrifice of posterior communication artery. Interv Neuroradiol 2017; 23:620-627. [PMID: 28825341 DOI: 10.1177/1591019917726092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report ischemic complications related to obstruction of the posterior communicating artery (PcomA) and suggest treatment strategies according to the angiographic characteristics of the PcomA and the posterior cerebral artery (PCA). Twenty-one patients with PcomA aneurysm who had initially undergone endovascular treatment and had an identifiable PcomA occlusion on immediate or follow-up angiography were enrolled. We classified PcomA aneurysm according to the characteristics of the PcomA and PCA (P1) on baseline angiography, as follows: type I was defined as PcomA aneurysm with an absent PcomA and a normal-sized P1. Type II was defined as a hypoplastic PcomA and a normal-sized P1. Type III was defined as a normal-sized PcomA and an absent P1. Type IV was defined as a normal-sized PcomA and a hypoplastic P1. Type V was a normal-sized PcomA and a normal-sized P1. Among all cases of PcomA obstruction, 15 (71.4%) were type II PcomA aneurysms, four were type IV, one was type III, and one was type V. Ischemic events related to PcomA obstruction occurred in three cases (type II, III and VI), which included two tuberothalamic infarctions (type III and IV) and one cortical infarction in the territory of the PCA (type II). Follow-up angiographies showed flow change in the PcomA in 14 cases. It is relatively safe to sacrifice type II PcomA if necessary. However, physicians should pay attention to unexpected flow changes, such as recanalization or occlusion of the PcomA, which are possible after treatment.
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Affiliation(s)
- Jung Ho Ko
- Department of Neurological Surgery, College of Medicine, Dankook University, Cheonan, Korea
| | - Young-Joon Kim
- Department of Neurological Surgery, College of Medicine, Dankook University, Cheonan, Korea
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Sandvig A, Lundberg S, Neuwirth J. Artery of Percheron infarction: a case report. J Med Case Rep 2017; 11:221. [PMID: 28800746 PMCID: PMC5554405 DOI: 10.1186/s13256-017-1375-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 07/02/2017] [Indexed: 11/25/2022] Open
Abstract
Background The artery of Percheron is a rare anatomic variant of arterial supply to the paramedian thalamus and rostral midbrain, and occlusion of the artery of Percheron results in bilateral paramedian thalamic infarcts with or without midbrain involvement. Acute artery of Percheron infarcts represent 0.1 to 2% of total ischemic stroke. However, of thalamic strokes, occlusion of artery of Percheron is the cause in 4 to 35% of cases. Early diagnosis of artery of Percheron infarction can be challenging because it is infrequent and early computed tomography or magnetic resonance imaging may be negative. Thus, it can be confused with other neurological conditions such as tumors and infections. Case presentation This is a retrospective case study of a 56-year-old white man admitted to Umeå University Hospital and diagnosed with an artery of Percheron infarction. Medical records and the neuroradiological database were reviewed, and the diagnosis was made based on typical symptoms and radiological findings of artery of Percheron infarction. We report the case of a 56-year-old man with a history of overconsumption of alcohol who was found in his home unconscious and hypothermic. He had a Reaction Level Scale-85 score of 4. He developed ventricular fibrillation on arrival at our emergency department, and cardiopulmonary resuscitation successfully restored sinus rhythm within an estimated 2 minutes of onset. He was then put on cardiopulmonary bypass for rewarming. The initial head computed tomography performed on admission was wrongly assessed as unremarkable. Bilateral ischemia in the paramedian thalamic nuclei and pons were first documented on a follow-up computed tomography on day 24 after hospitalization. He died on day 35 after hospitalization. Conclusions Artery of Percheron infarcts are rare. The radiological diagnosis can initially often be judged as normal and in combination with variability in the neurological symptoms it is a rather difficult condition to diagnose. For these reasons few clinicians have much experience with this type of infarct, which may delay diagnosis and initiation of appropriate treatment.
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Affiliation(s)
- Axel Sandvig
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University Hospital, Umeå, Sweden. .,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Sandra Lundberg
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University Hospital, Umeå, Sweden
| | - Jiri Neuwirth
- Department of Radiation Sciences, Umeå University Hospital, Umeå, Sweden
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Lin G, Zhang X, Hu B, Zou M, Chen S, Gong Y, Cheng B, He Z. Paramedian Thalamic Ischemic Infarction: A Retrospective Clinical Observation. Eur Neurol 2017; 77:197-200. [PMID: 28190011 DOI: 10.1159/000458705] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/26/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The study aimed to evaluate the clinical features in patients with bilateral and unilateral paramedian thalamic infarcts. METHODS Twenty-one patients with paramedian thalamic infarcts were included, and their case records were reviewed. We focused on the patients' neuroimaging and neurological symptoms including the duration of coma, vertical gaze palsy, and memory impairment. The causes of bilateral and unilateral paramedian thalamic infarcts were also investigated. RESULT Nine patients had bilateral paramedian thalamic infarcts and 12 patients had unilateral lesions. As an initial symptom, coma had occurred in 5 patients with bilateral lesions and 4 patients with unilateral lesions. Bilateral vertical gaze palsy and memory impairment were found in both groups. Most of them recovered well, except 1 patient who died due to bilateral thalamic paramedian infarction. CONCLUSIONS Our results show that both bilateral and unilateral paramedian thalamic infarcts can cause coma, vertical gaze palsy, and memory impairment. This may promote our understanding of paramedian thalamic infarction.
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Affiliation(s)
- Guoliang Lin
- Department of Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Lee A, Moon HI, Kwon HK, Pyun SB. Clinical Features of an Artery of Percheron Infarction: a Case Report. BRAIN & NEUROREHABILITATION 2017. [DOI: 10.12786/bn.2017.10.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Ahry Lee
- Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Korea
| | - Hyun Im Moon
- Department of Physical Medicine and Rehabilitation, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Hee-Kyu Kwon
- Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Korea
| | - Sung-Bom Pyun
- Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Korea
- Brain Convergence Research Center, Korea University Anam Hospital, Seoul, Korea
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Caruso P, Manganotti P, Moretti R. Complex neurological symptoms in bilateral thalamic stroke due to Percheron artery occlusion. Vasc Health Risk Manag 2016; 13:11-14. [PMID: 28053539 PMCID: PMC5189705 DOI: 10.2147/vhrm.s119395] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The artery of Percheron is a rare anatomical variant where a single thalamic perforating artery arises from the proximal posterior cerebral artery (P1 segment) between the basilar artery and the posterior communicating artery and supplies the rostral mesencephalon and both paramedian territories of the thalami. Almost one-third of human brains present this variant. Occlusion of the artery of Percheron mostly results in a bilateral medial thalamic infarction, which usually manifests with altered consciousness (including coma), vertical gaze paresis, and cognitive disturbance. The presentation is similar to the “top of the basilar syndrome”, and early recognition should be prompted. We describe the case of a young female with this vessel variant who experienced a bilateral thalamic stroke. Magnetic resonance angiography demonstrated bilateral thalamic infarcts and a truncated artery of Percheron. Occlusion of the vessel was presumably due to embolism from a patent foramen ovale. Thrombolysis was performed, with incomplete symptom remission, cognitive impairment, and persistence of speech disorders. Early recognition and treatment of posterior circulation strokes is mandatory, and further investigation for underlying stroke etiologies is needed.
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Affiliation(s)
- Paola Caruso
- Department of Clinical Neurology, University of Trieste, Trieste, Italy
| | - Paolo Manganotti
- Department of Clinical Neurology, University of Trieste, Trieste, Italy
| | - Rita Moretti
- Department of Clinical Neurology, University of Trieste, Trieste, Italy
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Becker-Bense S, Buchholz HG, Baier B, Schreckenberger M, Bartenstein P, Zwergal A, Brandt T, Dieterich M. Functional Plasticity after Unilateral Vestibular Midbrain Infarction in Human Positron Emission Tomography. PLoS One 2016; 11:e0165935. [PMID: 27824897 PMCID: PMC5100888 DOI: 10.1371/journal.pone.0165935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022] Open
Abstract
The aim of the study was to uncover mechanisms of central compensation of vestibular function at brainstem, cerebellar, and cortical levels in patients with acute unilateral midbrain infarctions presenting with an acute vestibular tone imbalance. Eight out of 17 patients with unilateral midbrain infarctions were selected on the basis of signs of a vestibular tone imbalance, e.g., graviceptive (tilts of perceived verticality) and oculomotor dysfunction (skew deviation, ocular torsion) in F18-fluordeoxyglucose (FDG)-PET at two time points: A) in the acute stage, and B) after recovery 6 months later. Lesion-behavior mapping analyses with MRI verified the exact structural lesion sites. Group subtraction analyses and comparisons with healthy controls were performed with Statistic Parametric Mapping for the PET data. A comparison of PET A of acute-stage patients with that of healthy controls showed increases in glucose metabolism in the cerebellum, motion-sensitive visual cortex areas, and inferior temporal lobe, but none in vestibular cortex areas. At the supratentorial level bilateral signal decreases dominated in the thalamus, frontal eye fields, and anterior cingulum. These decreases persisted after clinical recovery in contrast to the increases. The transient activations can be attributed to ocular motor and postural recovery (cerebellum) and sensory substitution of vestibular function for motion perception (visual cortex). The persisting deactivation in the thalamic nuclei and frontal eye fields allows alternative functional interpretations of the thalamic nuclei: either a disconnection of ascending sensory input occurs or there is a functional mismatch between expected and actual vestibular activity. Our data support the view that both thalami operate separately for each hemisphere but receive vestibular input from ipsilateral and contralateral midbrain integration centers. Normally they have gatekeeper functions for multisensory input to the cortex and automatic motor output to subserve balance and locomotion, as well as sensorimotor integration.
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Affiliation(s)
- Sandra Becker-Bense
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders-IFB, University of Munich, Munich, Germany
| | - Hans-Georg Buchholz
- Department of Nuclear Medicine, Johannes Gutenberg-University, Mainz, Germany
| | - Bernhard Baier
- Department of Neurology, Johannes Gutenberg-University, Mainz, Germany
| | | | - Peter Bartenstein
- German Center for Vertigo and Balance Disorders-IFB, University of Munich, Munich, Germany
- Department of Nuclear Medicine, University of Munich, Munich, Germany
- Munich Cluster of Systems Neurology (SyNergy), University of Munich, Munich, Germany
| | - Andreas Zwergal
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders-IFB, University of Munich, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders-IFB, University of Munich, Munich, Germany
- Institute for Clinical Neuroscience, University of Munich, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders-IFB, University of Munich, Munich, Germany
- Munich Cluster of Systems Neurology (SyNergy), University of Munich, Munich, Germany
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Abstract
INTRODUCTION Rarely, both paramedian thalami receive arterial blood flow from a single unilateral vessel arising from the first segment of 1 posterior cerebral artery. This artery has received the name of artery of Percheron (AP). There is no consensus regarding the true prevalence of this anatomical variant. Bilateral paramedian thalamic infarcts are uncommon (0.1% to 2% of ischemic strokes). The main cause is the occlusion of the AP due to cardioembolism. Diffusion-weighted magnetic resonance imaging demonstrates the lesion in the acute setting. MATERIALS AND METHODS From September 2004 to October 2011, we identified 5 patients who had bilateral paramedian thalamic infarcts. We describe clinical findings and diagnostic imaging patterns observed in these cases and review the literature. RESULTS Three men and 2 women with bilateral paramedian thalamic infarction probably due to occlusion of AP are described. Mean age at presentation was 58±24 years. Magnetic resonance imaging showed the lesion in all patients. Four patients presented loss of consciousness as initial symptom. Only 1 patient evidenced mesencephalic extension of the infarct on magnetic resonance imaging, although 4 presented abnormal ocular signs. No patients received intravenous thrombolisis because of delayed diagnosis. All patients were discharged home. A 90-year-old woman recovered completely and the other 4 subjects persisted with cognitive symptoms and gaze abnormalities. CONCLUSIONS Clinical presentation and imaging patterns described in this group of patients were similar to published data. High level of suspicion based on clinical and imaging findings is essential for early diagnosis of this rare condition. None of our patients had an early diagnosis of acute ischemic stroke and received proper thrombolytic treatment.
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Holekamp TF, Mollman ME, Murphy RKJ, Kolar GR, Kramer NM, Derdeyn CP, Moran CJ, Perrin RJ, Rich KM, Lanzino G, Zipfel GJ. Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases. J Neurosurg 2016; 124:1752-65. [DOI: 10.3171/2015.5.jns15473] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.
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Affiliation(s)
| | | | | | | | | | - Colin P. Derdeyn
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
- 5Neurology, and
| | - Christopher J. Moran
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
| | | | - Keith M. Rich
- Departments of 1Neurological Surgery,
- 4Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Missouri; and
| | - Giuseppe Lanzino
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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Acute Occlusion of the Percheron Artery during Pregnancy: A Case Report and a Review of the Literature. J Stroke Cerebrovasc Dis 2015; 25:572-7. [PMID: 26698643 DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 09/24/2015] [Accepted: 11/05/2015] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The Percheron artery (PA) is a rare variant vessel. Its acute occlusion can cause a bilateral symmetrical thalamic stroke, clinically manifested as a sudden alteration of consciousness that could vary from sleepiness to coma. In this paper, we illustrate a case of acute PA occlusion in a young, pregnant woman and present a review of the literature, focusing on the possible causes of the acute occlusion. METHODS A 35-year-old woman, at the fourth week of pregnancy, came to the emergency department of our hospital because of a sudden onset and persistent loss of consciousness. Brain magnetic resonance imaging (MRI) showed a symmetrical and bilateral thalamic infarction without evidence of other ischemic lesions, compatible with an acute PA occlusion. RESULTS The patient, who showed full clinical recovery within a few hours of symptom onset, received a short-term anticoagulant treatment followed by aspirin for long-term prevention. CONCLUSIONS We reviewed the literature about the possible causes of acute PA occlusion. This ischemic condition is usually associated with cardioembolic or small-vessel disease. However, in our patient, we did not find any element supportive for coagulative alteration or embolyzing conditions. PRACTICE The presence of this type of thalamic stroke should be considered in the management of persistent loss of consciousness. PA occlusion is rare, but it needs a brain MRI examination for a correct diagnosis, a narrow evaluation of all the possible causes, and a long-term anticoagulant therapy. Pregnancy itself should constitute a rare but possible cause of a PA occlusion.
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Zhou Y, Fox D, Anand A, Elhaj A, Kapoor A, Najibi F, Kim H, Weir R, Jayam-Trouth A. Artery of Percheron Infarction as an Unusual Cause of Korsakoff's Syndrome. Case Rep Neurol Med 2015; 2015:927809. [PMID: 26688763 PMCID: PMC4672116 DOI: 10.1155/2015/927809] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 11/09/2015] [Indexed: 12/05/2022] Open
Abstract
The Korsakoff syndrome is defined as "an abnormal mental state in which memory and learning are affected out of all proportion to other cognitive functions in an otherwise alert and responsive patient." Confabulation refers to false or erroneous memories arising, not deliberately, in the context of a neurological amnesia and is often thought of as pathognomonic of the Korsakoff syndrome. Although the exact pathophysiology is unknown, various studies have identified brain lesions in the thalami, mammillary bodies, and frontal cortex. We report a case of a 68-year-old male presenting with acute altered mental status on July 16, 2015. The neuropsychological dysfunctions included prominent Korsakoff's syndrome, which became apparent when the altered mental status resolved. Amnesia was accompanied by prominent confabulation, disorientation, and lack of insight into his own disability. Neuroradiological data indicated that the intralaminar and dorsomedial nuclei in bilateral thalami were infarcted by occlusion of the artery of Percheron. We believe that ours is one of few reported cases of Korsakoff syndrome in a patient with infarction involving the territory of the artery of Percheron. We conclude that bilateral thalamic lesions could cause Korsakoff's syndrome and the intralaminar and dorsomedial nuclei might be important structures in the pathogenesis of confabulation.
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Affiliation(s)
- Yongxing Zhou
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Derrick Fox
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Abhishek Anand
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Amal Elhaj
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Arushi Kapoor
- Department of Psychiatry, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Faranak Najibi
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Han Kim
- Department of Radiology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Roger Weir
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
| | - Annapurni Jayam-Trouth
- Department of Neurology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060, USA
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Galvez-Ruiz A. Post-traumatic Vertical Gaze Paresis in Nine Patients: Special Vulnerability of the Artery of Percheron in Trauma? Middle East Afr J Ophthalmol 2015; 22:370-6. [PMID: 26180479 PMCID: PMC4502184 DOI: 10.4103/0974-9233.159765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose: The purpose was to present a case series of vertical gaze paresis in patients with a history of cranioencephalic trauma (CET). Methods: The clinical characteristics and management are presented of nine patients with a history of CET secondary to motor vehicle accidents with associated vertical gaze paresis. Results: Neuroimaging studies indicated posttraumatic contusion of the thalamic-mesencephalic region in all nine patients who corresponded to the artery of Percheron region; four patients had signs of hemorrhagic transformation. Vertical gaze paresis was present in all patients, ranging from complete paralysis of the upward and downward gaze to a slight limitation of upward gaze. Discussion: Posttraumatic vertical gaze paresis is a rare phenomenon that can occur in isolation or in association with other neurological deficits and can cause a significant limitation in the quality-of-life. Studies in the literature have postulated that the unique anatomy of the angle of penetration of the thalamoperforating and lenticulostriate arteries makes these vessels more vulnerable to isolated selective damage in certain individuals and can cause-specific patterns of CET.
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Affiliation(s)
- Alberto Galvez-Ruiz
- Neuro-ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
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Artery of Percheron infarction: review of literature with a case report. Radiol Oncol 2015; 49:141-6. [PMID: 26029025 PMCID: PMC4387990 DOI: 10.2478/raon-2014-0037] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 08/20/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Clinical features indicating an ischemic infarction in the territory of posterior cerebral circulation require a comprehensive radiologic examination, which is best achieved by a multi-modality imaging approach (computed tomography [CT], CT-perfusion, computed tomography angiography [CTA], magnetic resonance imaging [MRI] and diffusion weighted imaging [DWI]). The diagnosis of an acute ischemic infarction, where the damage of brain tissue may still be reversible, enables selection of appropriate treatment and contributes to a more favourable outcome. For these reasons it is essential to recognize common neurovascular variants in the territory of the posterior cerebral circulation, one of which is the artery of Percheron. CASE REPORT A 69 year-old woman, last seen awake 10 hours earlier, presented with two typical clinical features of the artery of Percheron infarction, which were vertical gaze palsy and coma. Brain CT and CTA of neck and intracranial arteries upon arrival were interpreted as normal. A new brain CT scan performed 24 hours later revealed hypodensity in the medial parts of thalami. Other imaging modalities were not performed, due to the presumption that the window for the application of effective therapy was over. The diagnosis of an artery of Percheron infarction was therefore made retrospectively with the re-examination of the CTA of neck and intracranial arteries. CONCLUSIONS A multi-modality imaging approach is necessary in every patient with suspicion of the posterior circulation infarction immediately after the onset of symptoms, especially in cases where primary imaging modalities are unremarkable and clinical features are severe, where follow-up examinations are indicated.
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Goerlitz J, Wenz H, Al-Zghloul M, Kerl HU, Groden C, Förster A. Anatomical Variations in the Posterior Circle of Willis and Vascular Pathologies in Isolated Unilateral Thalamic Infarction. J Neuroimaging 2015; 25:983-8. [PMID: 25786673 DOI: 10.1111/jon.12235] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 01/13/2015] [Accepted: 02/04/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE To characterize relations between configurations of the posterior part of the Circle of Willis (CoW) and the occurrence of unilateral thalamic infarction. METHODS From a magnetic resonance imaging report database, we identified and analyzed 111 patients with acute isolated unilateral thalamic infarction on diffusion-weighted imaging (DWI). Vascular pathologies were noted on magnetic resonance angiography (MRA) and the diameter of the posterior communicating artery (PComA) and the P1 and P2 segments of the posterior cerebral artery determined. RESULTS Most infarctions were observed in the territory of the inferolateral arteries (70.2%), followed by the paramedian (16.3%), tuberothalamic (8.7%), and posterior choroidal arteries (4.8%). Relevant vascular pathologies included stenosis of the basilar artery (4.5%), P1 segment stenosis (4.5%)/occlusion (.9%), and P2 segment stenosis (14.4%)/occlusion (4.5%). Paramedian thalamic infarction was associated with ipsilateral P1 segment hypoplasia/absence (P < .001); tuberothalamic infarction with ipsilateral PComA hypoplasia/absence (P = .08). Furthermore, the diameter of the relevant CoW segment was smaller in patients with ipsilateral thalamic infarction. CONCLUSIONS Assessment of CoW configuration on MRA may be helpful to understand the appearance of unilateral thalamic stroke independent from stroke etiology. A smaller diameter of the relevant CoW segment might be a risk factor for ipsilateral thalamic stroke in the corresponding thalamic vascular territory.
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Affiliation(s)
- Johannes Goerlitz
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Holger Wenz
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mansour Al-Zghloul
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hans U Kerl
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Alex Förster
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
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