Delayed sudden coma due to artery of percheron infarction Item Type Journal Article Authors Rivera Lara, Lucia; Henninger, Nils Citation Arch Neurol. 2011 Mar;68(3):386-7. doi: 10.1001/ archneurol.2010.377. Link to article on publisher's site. DOI 10.1001/archneurol.2010.377 Rights Publisher PDF posted after 12 months as allowed by the publisher's author rights policy at http://archneur.jamanetwork.com/public/ instructionsForAuthors.aspx#SecEditorialPoliciesforAuthors. Download date 12/04/2024 17:20:29 Link to Item http://hdl.handle.net/20.500.14038/37765 IMAGES IN NEUROLOGY Delayed Sudden Coma Due to Artery of Percheron Infarction A 52- YEAR - OLD MAN was noted to display “unusual behavior” with transient agitation and blurry vision after otherwise uneventful diagnostic cardiac catheterization. Several hours after same-day discharge from the hospital, he suddenly became comatose, requiring intubation and admission to the intensive care unit. Two days later, he regained consciousness and was noted to have vertical gaze palsy and dysarthria without other neurologic deficits. Magnetic resonance imaging demonstrated bilateral acute medial thalamic ischemic strokes (Figure). Magnetic resonance angiography did not display extracranial or intracranial arterial stenosis (not shown). At 3 months’ follow-up, he had only mild residual dysarthria. COMMENT The thalamic vascular supply is categorized into the anterior, paramedian, inferolateral, and posterior territories.1 Percheron2 described 3 anatomic variations of the paramedian arteries: in the most common variant (type A), small perforating arteries arise from both P1 segments of the posterior cerebral artery. Type B, also called the artery of Percheron, is characterized by an asymmetrical common trunk arising from one P1 segment. Type C is defined by an arcade emanating from an artery bridging the two P1 seg- ments. Occlusion of the artery of Percheron characteristically results in bilateral medial thalamic infarction with or without rostral midbrain involvement.2 The clinical presentation may include disorientation, memory impairment, behavioral abnormalities, dysarthria, hypophonia, and dysprosody, often accompanied by eye movement abnormalities, including vertical gaze palsy.1,3 Impairment of arousal with decreased and fluctuating levels of consciousness is a remarkable characteristic frequently observed within the first few days.1 Coma may be the initial presenting symptom or it may develop progressively over time.2,4 However, to our knowledge, ours is the first report of delayed sudden coma complicating bilateral thalamic infarction with an innocuous prodrome. The patient described herein recovered almost completely, likely because his stroke was limited to the bilateral paramedian thalamus not involving the midbrain, which has previously been associated with a favorable outcome.4 His vertical gaze palsy may be explained by disruption of cortical inputs that traverse the thalamus on their way to the rostral interstitial medial longitudinal fasciculus. Lucia Rivera-Lara, MD Nils Henninger, MD Author Affiliations: Department of Neurology, University of Massachusetts Medical Center, Worcester. (REPRINTED) ARCH NEUROL / VOL 68 (NO. 3), MAR 2011 386 Correspondence: Dr Rivera-Lara, Department of Neurology, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655 (Lucia.RiveraLara @umassmemorial.org). Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Rivera-Lara and Henninger. Acquisition of data: Rivera-Lara. Analysis and interpretation of data: Rivera-Lara and Henninger. Drafting of the manuscript: Rivera-Lara and Henninger. Critical revision of the manuscript for important intellectual content: RiveraLara and Henninger. Administrative, technical, and material support: Rivera-Lara. Study supervision: Henninger. Financial Disclosure: None reported. REFERENCES 1. Schmahmann JD. Vascular syndromes of the thalamus. Stroke. 2003;34(9):2264-2278. 2. Percheron G. The anatomy of the arterial supply of the human thalamus and its use for the interpretation of the thalamic vascular pathology. Z Neurol. 1973;205(1):1-13. 3. Llinás RRU, Ribary U. Consciousness and the brain: the thalamocortical dialogue in health and disease. Ann N Y Acad Sci. 2001;929:166-175. 4. Lazzaro NA, Wright B, Castillo M, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol. 2010;31 (7):1283-1289. WWW.ARCHNEUROL.COM ©2011 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a University of Massachusetts User on 06/15/2016 A B C Figure. Magnetic resonance image of the brain indicating bilateral thalamic infarction. A, Fluid attenuated inversion recovery imaging showing high signal intensity in bilateral medial thalami (arrows). Axial diffusion-weighted image (B) and corresponding (C) apparent diffusion coefficient (ADC) map obtained 24 hours after symptom onset showing respective restricted diffusion and reduced ADC values (arrows), indicating acute bilateral paramedian thalamic infarction. (REPRINTED) ARCH NEUROL / VOL 68 (NO. 3), MAR 2011 387 WWW.ARCHNEUROL.COM ©2011 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a University of Massachusetts User on 06/15/2016