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

Abstract

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.

Keywords: Arteriovenous malformation; Artery of Percheron; Cerebral angiography; Post-angiographic obliteration rebleeding; Thalamic infarction.

Figure 1

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: (A) MRA showed a 2.5-cm left medial occipital lobe AVM* and (B) an engorged drainage vein+ at the pineal region can be observed in T1 sequence with contrast. *: Left occipital AVM +: Engorged drainage vein at the pineal region Technique: (A) GE Signa EXCITE 1.5T, axial MRA time-of-flight (TOF) sequence with contrast, TR 30 ms, TE 6.3 ms. (B) GE Signa EXCITE 1.5T, axial MRI T1 sequence with contrast, TR 11.59 ms, TE 5.116 ms.

Figure 2

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: Angiography (lateral view) indicated that the feeding artery of the AVM originated from the enlarged left posterior cerebral artery (PCA), and early opacification of the draining veins was mainly observed through the vein of Galen and into the straight sinus. *: Vein of Galen; +: Straight sinus Technique: Digital subtraction angiography of the left VA via a right transfemoral approach using a 5F H1 catheter.

Figure 3

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Angiographic total obliteration of left occipital AVM was demonstrated 3 years later after Cyberknife radiosurgery in 2008. Findings: Angiography indicated the absence of a definite residual AVM and a patent major dural sinus. Technique: Digital subtraction angiography of the left VA via a right transfemoral approach using a 5F H1 catheter.

Figure 4

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: Axial CT imaging indicated approximately 25 ml (4.6×3.3×3 cm3) of heterogeneous parenchymal hemorrhage* in the left occipital area with adjacent perifocal edema. Technique: CT: GE LightSpeed VCT, mAs 280, kVp 120, 0.7 mm slice thickness, no contrast. *: Left occipital intracerebral hematoma

Figure 5

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: Cerebral angiography through the left vertebral artery showed no evidence of residual AVM or abnormal filling defects in the arterial phase. However, the AOP can be observed in the arterial phase. (A) A-P view. (B) Lateral view. a. Basilar artery, b. Right PCA, c. AOP. Technique: Digital subtraction angiography of the left VA via a right transfemoral approach using a 5F H1 catheter.

Figure 6

Four blood supply variants of the thalamus and midbrain. Type I, the thalamus is supplied by the bilateral PCA through many perforators. Type IIa, the perforators arise from the unilateral PCA. Type IIb, the artery of Percheron arises from the unilateral mesencephalic or the P1 artery and supplies the bilateral thalamic nucleus. Type III, the perforating arteries arise from a single bridging artery that connects bilateral P1 segments.

Figure 7

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: Cerebral angiography through the left vertebral artery showed the AOP in the venous phase. A prolonged arterial phase of the AOP was observed even though the venous phase was nearly completed. This finding indicated an acute AOP infarction. (A) A-P view: The contrast agent accumulated in the artery of Percheron distribution and its two branches to the bilateral thalamus. (B) Lateral view: The enhancement of the sigmoid and transverse sinus suggests the venous phase of angiography; however, the artery of Percheron continued to be enhanced. a. Sigmoid sinus, b. Transverse sinus, c. AOP. Technique: Digital subtraction angiography of the left VA via the right transfemoral approach using a 5F H1 catheter.

Figure 8

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: (A) Focal diffusion-weighted imaging (DWI) hyperintensities* and (B) a decreased+ apparent diffusion coefficient (ADC) value at the bilateral thalami, which is consistent with acute infarction. (A) Diffusion-weighted imaging *: Bilateral thalamus hyperintensity lesions in DWI Technique: Siemens sonata 1.494T, axial DWI sequence without contrast, TR 4000 ms, TE 122 ms. (B) Apparent diffusion coefficient +: Bilateral thalamus hypointensity lesions in ADC Technique: Siemens sonata 1.494T, axial ADC sequence without contrast, TR 4000 ms, TE 122 ms.

Figure 9

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: The two T2 fluid attenuation inversion recovery (FLAIR) images indicated a heterogeneous intensity hematoma in the occipital region (a) and a hyperintense perifocal edema in the left temporal region (b). The sizes of the hematoma and perifocal edema were increased after 6 months. The mass effect increased and caused a deformity in the brainstem. A: MRI T2 FLAIR image in Oct. 2014. Technique: Siemens Trio TIM 3.0T, fluid attenuation inversion recovery (FLAIR) sequence without contrast, TR 1e+004 ms TE 93 ms. B: MRI T2 FLAIR image in Apr. 2014. Technique: Siemens sonata 1.494T, axial T2 FLAIR sequence without contrast, TR 9000 ms, TE 99 ms.

Figure 10

A 48-year-old female diagnosed with an acute infarction in the artery of Percheron distribution. Findings: The AVM histology specimen from this patient showed different severity levels of stenosis. A completely obliterated artery (a) and red cells in the partially obliterated artery lumen (b) were identified. Microcirculation was difficult to detect using angiography.