Isolated Bilateral Cerebral Peduncular Infarction Manifesting Pseudobulbar Palsy and Quadriparesis: a Case Report

Abstract

Bilateral cerebral peduncular infarction (BCPI) is a very rare disorder among stroke patients. The main clinical manifestations in the previously reported BCPI case reports was associated with locked-in syndrome or persistent vegetative state. Here, we present a 51-year-old woman who had pseudobulbar palsy and quadriplegia. Magnetic resonance imaging showed an acute infarction in the middle areas of the cerebral peduncle with a unique "Mickey Mouse ears" sign. Diffusion tensor imaging and tractography showed relatively preserved corticospinal tracts, but the corticobulbar tracts were not detected. Magnetic resonance angiography showed posterior cerebral artery and vertebrobasilar artery occlusion. Cerebral perfusion insufficiency due to stenosis or occlusion of the vertebrobasilar artery and its branches may lead to BCPI. The prognosis and clinical manifestations of BCPI are related to the extent of the infarction in the involved cerebral peduncle and whether other territories are involved. Isolated BCPI may present a severe pseudobulbar palsy with relatively preserved limb function depending on the involvement pattern.

Keywords: Brain Stem Infarctions; Cerebral Peduncle; Pseudobulbar Palsy; Vertebrobasilar Insufficiency.

Fig. 1. (A) High signal intensity in bilateral cerebral peduncles (arrowhead) on the diffusion-weighted image. (B) Apparent diffusion coefficient image showing corresponding hypointensity in bilateral cerebral peduncles (April 2020).

Fig. 2. (A) Magnetic resonance angiography showing vertebrobasilar artery and bilateral posterior cerebral artery occlusion (arrow) and right M1 artery focal stenosis (arrowhead). (B) Parasagittal T1-weighted magnetic resonance imaging demonstrates a linear structure (arrows) in the pontine cistern, suggesting basilar artery thrombosis (April 2020).

Fig. 3. (A) Follow-up brain magnetic resonance imaging showing an increased extent of diffusion-restricted lesions at bilateral cerebral peduncles on diffusion-weighted image. (B) Apparent diffusion coefficient image showing corresponding increased extent of lesions in bilateral cerebral peduncles (arrowhead) (May 2020).

Fig. 4. DTI and tractography showed partially preserved corticospinal tracts. The corticobulbar tract was not detected on DTI and tractography (June 2020).

DTI, diffusion tensor imaging.