Artery of Percheron infarction: A case report and literature review

Abstract

The artery of Percheron (AOP) represents a rare anatomic variant of the posterior circulation. It is a solitary trunk that provides bilateral arterial supply to the rostral midbrain and paramedian thalamus. AOP infarction presentation varies, most often presents with altered mental status, memory impairment, and supranuclear vertical gaze palsy. Diagnosis of the AOP infarct is most often missed in the initial CT scan. A majority of these diagnoses are made outside the window of thrombolytic treatment for ischemic stroke. We report a case of a 67-year old male with a history of well-managed diabetes mellitus type 2 and hypertension, presented in the ER sudden onset severe drowsiness. On a physical exam, we found left pupil dilation and left eye deviation. Initial CT scan showed no pathological changes. The diagnosis was made on the third day of hospitalization via an MRI. Our case highlights the unusual presentation and that an absence of evidence of AOP infarction in CT scan does not exclude its diagnosis. The artery of the Percheron infarct requires a comprehensive clinical and radiological examination.

Keywords: Bilateral infarction; Diagnostic imaging; Infarction of the Percheron artery; Ischemic stroke; Paramedian arteries.

Fig. 1

Fig. 2

Axial T2-weighted image shows symmetrical hyperintense lesions presented in the paramedial thalamus.

Fig. 3

FLAIR hyperintense signals demonstrate bilateral paramedian thalami and paramedial mesencephalon—in the territory of the penetrating arteries.

Fig. 4

Coronal FLAIR sequence presenting hyperintense symmetrical lesions presented in the paramedial thalamus.

Fig. 5

In the sequences mentioned above lesions have hyperintensity in FLAIR and T2-weighted images while presenting water diffusion restriction in DWI- ADC hereby findings indicate—confirm diagnosis of Percheron artery infarction.