Artery of Percheron infarction: a case report

Navigating the clinical landscape of artery of Percheron infarction: A systematic review

Introduction

Infarction of the artery of Percheron (AOP) is a rare vascular condition where a single arterial branch supplies blood to the thalamic and midbrain regions, leading to neurological deficits. The challenge lies in its often-delayed diagnosis due to its rarity and diverse clinical presentations, necessitating heightened awareness among clinicians for expedited diagnosis and appropriate therapeutic interventions.

Materials and methods

All relevant studies involving patients diagnosed with infarction of AOP were retrieved from PubMed, Google Scholar, Web of Science, and Scopus. Only human studies that were published in full English-language reports were included. Included in the search were the terms "Artery of Percheron," "infarction," "stroke," and "demarcation". Age, gender, presenting symptoms, treatment, recovery time, and outcome of patients with AOP infarction were all recorded.

Results

A systematic review was conducted on a total of 530 articles, out of which 130 articles met the specified requirements. The average age is 59, with men comprising 57.7% of the population. The symptoms reported were visual disturbance in 43.9% of cases and changed mental state in 77.2% of cases. Treatment options include conservative management (85.4%), thrombolysis (11.3%), and other approaches. The optimal age range for recovery is between 41 and 50 years old.

Conclusion

Our study on acute AOP infarction highlights male predominance, common comorbidities like hypertension and diabetes, and prevalent symptoms including visual disturbance and altered mental state. Early recognition is crucial, with thrombolytic therapy within the critical time window showing promising outcomes. These findings offer insights for enhanced clinical management of AOP infarction.

Successful Thrombolysis in Artery of Percheron Infarction: Grabbed an Extremely Rare Opportunity

Artery of Percheron (AOP) is an uncommon anatomical variation in the posterior circulation neurovasculature. It is a single artery arising from P1 segment of posterior cerebral artery (PCA) which supplies bilateral paramedian thalami and the rostral midbrain and as a result, occlusion of it leads to bilateral thalamic and mesencephalic infarction. Due to very low incidence (ranges from 0.1% to 2% of all ischemic strokes) and varied presentation, the diagnosis of AOP infarction requires strong clinical and radiological suspicion and hence, AOP infarction is often missed and patients are rarely thrombolysed. Here we discuss a patient with acute altered sensorium who recovered completely in short time following treatment with intra-venous thrombolysis for bilateral medial thalamic ischemic stroke due to AOP occlusion.

When a Hypersomnolent Hemodialyzed Patient Actually Has a Rare Stroke: A Case of Artery of Percheron Infarction With Paradoxical Embolism

INTRODUCTION

Artery of Percheron (AOP) is an uncommon anatomic variant of the arterial supply of the medial thalami. Owing to variable clinical presentation, challenging imaging diagnosis, and its rarity, it is difficult to diagnose AOP infarctions. We present a clinical case of a unique presentation of AOP infarction associated with paradoxical embolism and highlight the atypical clinical manifestations and challenging diagnosis of this stroke syndrome.

CASE REPORT

A 58-year-old White female with chronic renal insufficiency on hemodialysis was admitted to our center with a 10-hour course of hypersomnolence and right-sided ataxia. She had normal body temperature, blood pressure, peripheral oxygen saturation, and heart rate and scored 11 points in the Glasgow Coma Scale and 12 points in National Institutes of Health Stroke Scale. Initial brain computerized tomography scan, electrocardiogram, and thoracic radiography were normal; transcranial Doppler ultrasound showed >50% stenosis at the P2 segment of the right posterior cerebral artery, and transthoracic echocardiogram, a patent foramen ovale and thrombus adherent to the hemodialysis catheter. On day 3, she underwent brain magnetic resonance that showed acute ischemic lesions at the paramedian thalami and the superior cerebral peduncles. AOP infarction due to a paradoxical embolism from a patent foramen ovale with a right atrial thrombus was the final diagnosis.

CONCLUSIONS

AOP infarctions are a rare type of stroke with elusive clinical presentations and frequently, initial imaging assessment is normal. Early recognition is crucial, and a high index of suspicion is needed to suspect this diagnosis.

Bilateral thalamic infarct involving artery of Percheron: a case report

Introduction and importance

The thalamus and the midbrain have marked variations and overlapping in their blood supply; one of those variations is the artery of Percheron. Artery of Percheron occlusion is a rare cause of infarction in the bilateral thalamus and midbrain.

Case presentation

In this case, a 60-year-old female with chronic hypertension presented with unconsciousness, motor impairments, and oculomotor disorders.

Clinical discussion

Due to highly variable clinical manifestations and possible negative findings during initial imaging, these conditions are often overlooked, causing delays in therapeutic intervention and leading to bad patient prognosis. Various imaging techniques can be used for diagnosis and treatment should be started early. The treatment aims to promote recanalization as soon as possible and prevent future episodes. The involvement of the midbrain is unfavourable.

Conclusion

Early clinical assessment and neuroimaging are vital for timely diagnosis and early administration of therapeutic measures for better patient prognosis.

Artery of Percheron Infarction: A Rare But Important Cause of Bilateral Thalamic Stroke

Artery of Percheron infarction is a serious but rare condition that can result in acute bilateral thalamic infarction and a wide range of neurological symptoms. It occurs due to occlusion of the single arterial branch that supplies the medial thalamus and rostral midbrain bilaterally. In this case report, we describe a 58-year-old female with a history of hypertension and hyperlipidemia who presented with sudden confusion, speech difficulties, and right-sided weakness. An initial CT scan showed ill-defined hypodensity in the left internal capsule, which, when combined with the clinical features, suggested acute ischemic stroke. The patient received an IV tissue plasminogen activator within the recommended time window. Several days later, repeated imaging showed bilateral thalamic hypodensity consistent with subacute infarction in the territory of the artery of Percheron. The patient was subsequently discharged to a rehabilitation facility for further recovery and rehabilitation with residual mild hemiparesis. It is important for healthcare providers to maintain a high index of suspicion for the artery of Percheron infarction and be aware of its potential to cause acute bilateral thalamic infarction and a variety of neurological symptoms.

Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis

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.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.

Case report: Artery of Percheron infarction as a rare complication during atrial fibrillation ablation

The incidence of stroke or transient ischemic attacks (TIA) in atrial fibrillation (AF) catheter ablation procedures is around 1% and may be unnoted under anesthesia. The artery of Percheron (AOP) infarction is a rare kind of stroke with heterogeneity in manifestation, which further makes the perioperative early detection and diagnosis a challenge. Herein, we present one patient who underwent AF ablation and presented mental status alteration after withdrawing anesthetics. An emergency head CT was obtained, which revealed no apparent pathological changes. A late MRI test confirmed the diagnosis of AOP infarction. With oral anticoagulants and rehabilitation therapies, the patient’s awareness improved and fully recovered on the sixth-month follow-up. Variability in manifestation, no positive radiological finding on initial CT, and a low incidence has made few clinicians to gain much experience with this type of infarct, which delays the diagnosis and initiation of appropriate treatment.

Clinimetric study and review of the Reaction Level Scale

OBJECTIVES

Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated.

MATERIALS AND METHODS

A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated.

RESULTS

Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κ_w >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS.

CONCLUSIONS

The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.

Artery of Percheron Infarction: A Case Report of Bilateral Thalamic Stroke Presenting with Acute Encephalopathy

The artery of Percheron (AOP) is a relatively rare anatomic variant in which a solitary arterial trunk branches from the proximal segment of the posterior cerebral artery and provides arterial supply to the paramedian region of the thalami bilaterally and often to the rostral part of the midbrain. Occlusion of the artery of Percheron results in bilateral paramedian thalamic infarcts with and without midbrain involvement. Recognition of this condition as an acute stroke may be challenging due to various nonlocalized clinical presentations, given the wide range of neurological functions subserved by the thalamus. Prompt neuroimaging, preferably with magnetic resonance imaging (MRI), in conjunction with familiarity with this relatively rare vascular variation can facilitate initiation of appropriate time contingent thrombolytic treatment and improved long-term prognosis. We present a case of a 56-year-old African American female with a bilateral thalamic infarct secondary to the artery of Percheron thromboembolism. This patient presented unresponsive without focal neurologic findings but with an initial Glasgow Coma Score (GCS) of 7, and subsequent computed tomographic (CT) head revealed bilateral thalamic hypodensities. Confirmatory MRI exhibited bilateral subacute thalamic infarcts, which were thought to be embolic with the source from the left ventricular thrombus as the patient had at least three distinct clots. Unfortunately, the patient’s mental status did not improve significantly, and she was discharged to a nursing facility for extended care. AOP infarction may be missed on vascular imaging utilizing CT, MRI, and even catheter angiography. Clinical recognition that the AOP is one of the only single artery occlusions that can affect bilateral structures and frequently present solely as altered mental status without focal neurologic deficits is crucial to the diagnosis.

Posterior Circulation Ischaemic Stroke

Posterior circulation ischaemic stroke (PCIS) is a disease of high burden. They account for 20-25% of all ischaemic strokes. However, it is relatively under-researched and requires more clinical attention, since it carries worse functional outcomes. Vertigo, visual disturbances and sensory/motor disturbances are found in PCIS. Large artery atherosclerosis and embolism are main causes of PCIS, while there is growing evidence that vertebrobasilar dolichoectasia is a key association. Hypertension is the commonest risk factor, while diabetes mellitus is more specific to PCIS. PCIS is diagnosed through neuroimaging techniques, which examine structural brain abnormalities, vascular patency and perfusion. PCIS, in line with ischaemic stroke in general, requires medical treatment and lifestyle modifications. This includes smoking cessation, weight control, and dietary alterations. Aspirin use also significantly improves survival outcomes. While intravascular and intra-arterial thrombolysis improve clinical outcomes, this is not proven conclusively for stenting and angioplasty. Future research on PCIS can focus on multi-centre epidemiological studies, clinically significant anatomical variants, and collateralisation.

Bilateral Thalamic Stroke Arising From an Occlusion of the Artery of Percheron: Barriers to Diagnosis, Management, and Recovery

A 90-year-old male patient presented with excessive somnolence, right-sided weakness, and left facial droop. CT and MRI scans of the head, taken several days after initial head CT proved to be non-revealing, demonstrated a bilateral thalamic stroke, a rare phenomenon. The infarct arose in the territory of the artery of Percheron, an anatomic variant in which a single artery supplies both sides of the thalamus and midbrain. When this artery becomes occluded, it results in severely dysregulated consciousness and alertness. This type of stroke proved challenging for the medical team, due to poor resolution of initial imaging, as well as the therapy teams, due to the constant need for sleep. This case report outlines how barriers in diagnosis and management make knowledge of the artery of Percheron and its occlusion crucial to patient care and recovery.

Intravenous thrombolytic therapy for cerebral infarction due to the Persheron artery occlusion. Case report

Occlusion of the artery of Percheron is the cause of bilateral thalamic infarctions, sometimes involving structures of the midbrain. A clinical case of intravenous thrombolytic therapy for ischemic stroke due to the occlusion of the Percheron artery in a 72-year-old female patient who developed depression of consciousness, oculomotor disorders, dysarthria, ataxia, pyramidal disorders, and cognitive disorders is presented. Magnetic resonance imaging, which detected bilateral thalamus paramedian infarction in the acute stage, made it possible to diagnose the occlusion of the Percheron artery. Intravenous thrombolysis led to a rapid regression of symptoms; at the end of the acute period of the disease, the patient was discharged from the hospital with a slight neurological deficit and with a good functional outcome. After a one year the dynamic observation revealed persistent mild cognitive disorders; magnetic resonance imaging showed small symmetric cystic-gliosis changes in the medial parts of the thalamus on both sides. Timely diagnosis and intravenous thrombolytic therapy contribute to a good outcome of cerebral infarction due to the Percheron's artery occlusion.

Artery of Percheron in the Differential Diagnosis of Acute Altered Mental Status

Bilateral thalamic infarction is a rare entity (it occurs in 0.6% of ischemic strokes) and can be confused with other vascular etiologies such as basilar syndrome and deep cerebral venous thrombosis, as well as neoplasms, infections, or toxins. It is typically characterized by the triad of altered mental status, vertical gaze paralysis, and memory impairment, although their symptoms can be highly variable. We describe the case of a young man who came to the emergency department presenting diplopia, speech alteration, and decreased level of consciousness with frequent fluctuations. Baseline computerized tomography was normal, and because of the clinical findings, thrombolysis was performed. Subsequently made magnetic resonance showed a bilateral acute thalamic infarction caused by an obstruction of the Percheron artery. Although Percheron syndrome has been previously described in medical journals, our case is an unusual case in which we could perform an acute intravenous thrombolytic treatment. Besides, it is important for emergency physicians to enclose the Percheron syndrome in the differential diagnosis of coma in young people so that emergent treatments such as thrombolysis can be employed.

A Patient with a Delayed Diagnosis of Artery of Percheron Occlusion in Whom Thrombectomy Was Effective

Objective

A case of posterior cerebral artery (P1 segment) occlusion with consciousness disturbance and Weber's syndrome treated by mechanical thrombectomy is reported.

Case Presentation

The patient was a 69-year-old man with consciousness disturbance, left hemiparesis, and anisocoria. MRI revealed acute cerebral infarction in the midbrain and right thalamus. Angiography demonstrated that the right P1 segment was occluded and mechanical thrombectomy was performed. The right P1 segment and its perforator artery, the artery of Percheron (AOP), were both recanalized after the treatment, and the symptoms of perforator occlusion significantly improved.

Conclusion

Mechanical thrombectomy for P1 segment occlusion may be effective for improving the symptoms caused by occlusion of its perforator, the AOP.

Bilateral Thalamic Infarction Secondary to Thrombosis of Artery of Percheron

The artery of Percheron (AOP) is a rare anatomical variation emerging from the posterior circulation and supplies both thalami in the brain. As per the literature, the AOP infarction constitutes less than 2% of all stroke cases. AOP infarctions are usually caused by a combination of risk factors and a predisposing vascular territory. The areas most affected by AOP are the paramedian thalami with or without the involvement of the midbrain. AOP can be challenging as it is infrequent and mostly can be missed on the initial scans. We present a 58-year-old previously healthy male known to have hypertension with poor follow-up who presented with dysarthria and facial weakness, which he felt after waking up from sleep. After the initial physical examination and investigations, a preliminary diagnosis of stroke was made. As the patient was worked up for the stroke, his symptoms improved, and he was back to his baseline function within 48 hrs of presentation. What came to our surprise was that the stroke workup, including the initial CT scan with an angiogram, blood works (Hba1c and lipid panel), echocardiogram of the heart (ECHO), and Holter monitor was all unremarkable until an MRI head was done, which showed bilateral thalamic acute-sub acute infarct. This shows that AOP can be easily missed as it may not appear on the initial scans and workup and needs an adequate radiological study for diagnosis. Although some cases of AOP infarction are reported in the literature, the presentation with transient mild symptoms makes our case an interesting one.

Clinical Analysis of Bilateral Thalamic Infarction Caused by Percheron Artery Occlusion

The Percheron artery (artery of Percheron, AOP) is a rare variant vessel. Its acute occlusion can cause a bilateral symmetrical thalamic stroke; typical symptoms of bilateral paramedian thalamic infarcts due to occlusion of AOP are vertical gaze palsy, memory impairment, confusion, drowsiness, hypersomnolence, or coma. We present the MR imaging findings in two cases with cerebral infarction caused by Percheron artery occlusion. Due to the difficulty in the diagnosis of acute Percheron arterial infarction, early conservative treatment is used. The prognosis of the disease is poor, with few patients completely rehabilitating. Therefore, clinicians must understand the characteristics of the disease, provide early diagnosis and administer timely and effective treatment to reduce the patient's disability rate and fatality rate and therefore improve the quality of life of patients. The patient's prognosis has extraordinary significance.

ARTERY OF PERCHERON BRAIN INFARCTION: REVIEW OF LITERATURE AND CLINICAL CASE

Artery of Percheron is an anatomical version of the cerebral vessels, in which one artery, departing from the proximal part of one of the posterior cerebral arteries, supplies the paramedial thalamus and the rostral part of the midbrain. The Artery of Percheron brain infarction is often manifested by impaired consciousness, oculomotor disorders and neuropsychological symptoms. The diagnosis of the Artery of Percheron brain infarction is carried out using computed and/or magnetic resonance imaging (MRI). Intravenous thrombolysis and endovascular treatment methods are used in therapeutic window. Further secondary prevention is recommended. The prognosis is favorable with the timely treatment. A clinical case of a 43-year-old woman with acute oculomotor disorders is presented. A neurological examination revealed paresis of the vertical gaze, diplopia. MRI showed a bilateral acute infarction of both paramedial thalamuses. An angiographic study revealed saccular aneurysm of the A1 segment of the right anterior cerebral artery. After treatment, the patient was discharged with minimal neurological deficit.

Artery of Percheron infarction presenting as nuclear third nerve palsy and transient loss of consciousness: a case report

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.

Uncommon Association of Two Anatomical Variants of Cerebral Circulation: A Fetal-Type Posterior Cerebral Artery and Inferred Artery of Percheron, Complicated with Paramedian Thalamomesencephalic Stroke-Case Presentation and Literature Review

Background

The unilateral fetal variant of the posterior cerebral artery (FPCA) is characterized by the congenital absence of the P1 arterial segment. The artery of Percheron (AOP) is an uncommon vascular variant, in which a single dominant thalamoperforating arterial trunk arises from one P1 segment, bifurcates, and provides bilateral supply to the paramedian thalami and rostral midbrain.

Case Presentation

This is a retrospective case study of a 37-year-old man with multiple lifestyle risk factors (chronic marijuana and tobacco abuse), who suffered a thalamomesencephalic stroke, rapidly worsening to comatose state. After restoration of consciousness, he clinically manifested with left paramedian midbrain syndrome. Imaging demonstrated an asymmetric paramedian thalamic infarction with mesencephalon extension, patency of the basilar, vertebral arteries, and left PCA and right-sided FPCA, respectively. Left-sided thalamoperforating arterioles were not differentiated; AOP was inferred. Neither evident clinical source of embolus nor prothrombotic states were found. Mobile cardiac telemetry and transesophageal echocardiography were not available. The diagnosis was established too late for thrombolytic treatment. Anticoagulation was indicated during the acute and subacute stages, followed by low dose of antiplatelet.

Discussion

This uncommon cerebrovascular configuration (FPCA+AOP) might be the fourth case described in the literature. Sustained rehabilitation and abstinence from tobacco and cannabis led to favorable outcomes.

Acute Infarction in the Artery of Percheron Distribution during Cerebral Angiography: A Case Report and Literature Review

Improvements in techniques, contrast agents, and catheter design have significantly decreased angiography-related neurological deficits and complications. This article reports a case involving an angiographic total obliteration arteriovenous malformation (AVM) in a patient with an acute infarction in the artery of Percheron (AOP) distribution following angiography. Furthermore, imaging of an AOP acute infarction in cerebral angiography is presented.

Artery of Percheron: an unusual stroke presentation

An 86-year-old woman was admitted with multiple episodes of transient loss of consciousness. She was initially treated for seizures, and stroke was not considered likely. MRI on the same day of admission showed acute bilateral medial thalamic infarcts in keeping with the Artery of Percheron (AOP) territory infarcts. Investigation for polycythaemia and thrombocytosis showed JAK2 positive myeloproliferative neoplasm.A diagnosis of AOP infarction is often missed or delayed because it is rare and presents with variable neurological symptoms. Initial imaging in the form of CT is often negative, and some report that initial MRI findings may also be normal.An awareness of a wide range of differential diagnoses alongside a multi-modality imaging approach is required to reach a diagnosis.Although there are several other case reports of AOP infarction in the literature, this is the first to present with transient symptoms initially mistaken for seizure activity.