An Analysis of Clinical Characteristics of Rare Bilateral Cerebral Peduncular Infarction

Abstract

Objective: To investigate the anatomical characteristics, clinical manifestations, and imaging features of bilateral cerebral peduncular infarction. Methods: A retrospective analysis was performed on 11 patients diagnosed with bilateral cerebral peduncular infarction in the Affiliated Hospital of Xuzhou Medical University from December 2014 to December 2018. Their clinical and imaging features were analyzed and summarized in combination with the relevant national and international literature. Results: Among all the patients, there were eight cases with a history of hypertension, four cases with a history of diabetes mellitus, and four cases with a history of smoking. Conscious disturbance was observed in nine cases, quadriplegia in seven cases, pseudobulbar paralysis in three cases, and ataxia in one case. Brain magnetic resonance (MR) scans of bilateral cerebral peduncles showed patchy abnormal shadows with a hypointense signal on T1-weighted imaging (T1WI) and apparent diffusion coefficient (ADC) and hyperintense signal on T2-weighted imaging (T2WI), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). Computed tomography angiography (CTA) scans of head and neck showed severe stenosis or occlusion of vertebral artery, basilar artery, or posterior cerebral artery. All the patients received standardized treatment for cerebral infarction. Six patients died while five were left disabled. Conclusion: Bilateral cerebral peduncle infarction may be related to cerebral perfusion insufficiency caused by the stenosis or occlusion of vertebrobasilar artery and its branches. The main clinical manifestations are locked-in syndrome and persistent vegetative state. The specific imaging feature of "Mickey Mouse ear"-like infarction is associated with a poor prognosis.

Keywords: bilateral cerebral peduncular infarction; locked-in syndrome; neuroimaging; persistent vegetative state; “Mickey Mouse ears” sign.

Figure 1

(A–D) Case 7. Brain MRI: The lesions appear hyperintense on T2WI, T2-FLAIR, and DWI, and hypointense on ADC. Brain CTA: Stenoses are located in bilateral VA. (E–H) Case 8. Brain MRI: The lesions appear hyperintense on T2WI, T2-FLAIR, and DWI, and hypointense on ADC. Brain CTA: Stenosis is located in BA. (I–L) Case 10. Brain MRI: The lesions appear hyperintense on T2WI, T2-FLAIR, and DWI, and hypointense on ADC. Brain CTA: Stenoses are located in right VA and BA.

Figure 2

Diagrams of the blood supply of the midbrain. LMB, Lateral Mesencephalic Branches; ST, Spinoreticular Tract; ML, Medial Lemniscus; CTT, Central Tegmental Tract; SN, Substantia Nigra; RN, Red Nucleus; CP, Cerebral Peduncular; SCA, Superior Cerebellar Artery; IMMB, Inferior medial Mesencephalic Branch; FT, Frontopontine Tract; TC, Tractus Corticobulbrais; CT, Corticospinal Tract; DMB, Dorsal Mesencephalic Branch.

Figure 3

Distribution of blood supply of the midbrain. PChA, Posterior choroidal artery; PcoA, Posterior communicating artery; IF, interpeduncular fossa.