Location
Suwanee, GA
Start Date
6-5-2025 1:00 PM
End Date
6-5-2025 4:00 PM
Description
Introduction
The Artery of Percheron (AOP) is a rare anatomical variant in which a single arterial branch from the posterior cerebral artery supplies the rostral midbrain and ventromedial thalami bilaterally. Infarction of the AOP presents a diagnostic challenge due to its subtle imaging findings and diverse clinical manifestations, which may include cognitive impairment, ocular movement disorders, motor deficits, and altered consciousness.
Objectives
This case report aims to highlight the clinical presentation, diagnostic challenges, and management of AOP infarction. By presenting a case of AOP-related stroke following cataract surgery, we emphasize the importance of early recognition and appropriate imaging to improve patient outcomes.
Methods
We describe the case of a 62-year-old male who developed a thalamic stroke due to AOP infarction following right eye cataract surgery. Clinical presentation, diagnostic imaging, and management were reviewed to understand the pathophysiology and challenges associated with this rare condition.
Results
The patient, with a history of hypertension and hyperlipidemia, was brought to the emergency department in an obtunded state approximately 11 hours postoperatively. His neurological examination revealed a Glasgow Coma Scale (GCS) score of 3 and a National Institutes of Health Stroke Scale (NIHSS) score of 18. Initial laboratory findings were largely unremarkable, except for a positive urine drug screen for benzodiazepines and fentanyl, likely related to perioperative anesthesia. A non-contrast head computed tomography (CT) showed mild patchy white matter disease but no clear infarction. Computed tomography angiography (CTA) revealed atherosclerotic changes without high-grade stenosis or occlusion. However, magnetic resonance imaging (MRI) of the brain later demonstrated acute infarcts in the bilateral thalami and right posterior periventricular white matter, consistent with AOP infarction.
Approximately 20 hours post-admission, the patient experienced neurological worsening with an NIHSS increase from 17 to 20, prompting a second stroke alert. A repeat non-contrast CT confirmed evolving bilateral thalamic infarction without hemorrhagic transformation. By day 3 of admission, the patient exhibited fluctuating consciousness, memory deficits, ocular movement abnormalities, and motor impairments, including difficulty with downward gaze in the left eye and right leg weakness. His cognitive deficits included significant retrograde amnesia, difficulty recognizing familiar individuals, and impaired reading ability. He was ultimately discharged to inpatient rehabilitation with recommendations for secondary stroke prevention.
Conclusion
AOP infarction is an uncommon and underdiagnosed cause of ischemic stroke, often presenting with altered mental status and ocular abnormalities. Its rarity, coupled with the limitations of early imaging, contributes to diagnostic delays and exclusion from thrombolytic therapy. This case underscores the importance of recognizing AOP infarction as a differential diagnosis in patients presenting with sudden neurological decline, particularly after non-neurological surgical procedures. Given the patient’s same-day surgery, anesthesia exposure, and cardiovascular risk factors, these elements may have played a role in precipitating the infarction.
Clinicians must maintain a high index of suspicion for AOP infarction in patients with acute unexplained neurological deterioration. Advanced imaging techniques, particularly diffusion-weighted MRI, are essential for early diagnosis and appropriate management. Increased awareness of this rare condition may facilitate earlier intervention and improve patient outcomes in similar cases of posterior circulation infarction.
Embargo Period
5-28-2025
Included in
A Rare Presentation of Thalamic Stroke Due to Infarction of the Artery of Percheron Post Cataract Surgery
Suwanee, GA
Introduction
The Artery of Percheron (AOP) is a rare anatomical variant in which a single arterial branch from the posterior cerebral artery supplies the rostral midbrain and ventromedial thalami bilaterally. Infarction of the AOP presents a diagnostic challenge due to its subtle imaging findings and diverse clinical manifestations, which may include cognitive impairment, ocular movement disorders, motor deficits, and altered consciousness.
Objectives
This case report aims to highlight the clinical presentation, diagnostic challenges, and management of AOP infarction. By presenting a case of AOP-related stroke following cataract surgery, we emphasize the importance of early recognition and appropriate imaging to improve patient outcomes.
Methods
We describe the case of a 62-year-old male who developed a thalamic stroke due to AOP infarction following right eye cataract surgery. Clinical presentation, diagnostic imaging, and management were reviewed to understand the pathophysiology and challenges associated with this rare condition.
Results
The patient, with a history of hypertension and hyperlipidemia, was brought to the emergency department in an obtunded state approximately 11 hours postoperatively. His neurological examination revealed a Glasgow Coma Scale (GCS) score of 3 and a National Institutes of Health Stroke Scale (NIHSS) score of 18. Initial laboratory findings were largely unremarkable, except for a positive urine drug screen for benzodiazepines and fentanyl, likely related to perioperative anesthesia. A non-contrast head computed tomography (CT) showed mild patchy white matter disease but no clear infarction. Computed tomography angiography (CTA) revealed atherosclerotic changes without high-grade stenosis or occlusion. However, magnetic resonance imaging (MRI) of the brain later demonstrated acute infarcts in the bilateral thalami and right posterior periventricular white matter, consistent with AOP infarction.
Approximately 20 hours post-admission, the patient experienced neurological worsening with an NIHSS increase from 17 to 20, prompting a second stroke alert. A repeat non-contrast CT confirmed evolving bilateral thalamic infarction without hemorrhagic transformation. By day 3 of admission, the patient exhibited fluctuating consciousness, memory deficits, ocular movement abnormalities, and motor impairments, including difficulty with downward gaze in the left eye and right leg weakness. His cognitive deficits included significant retrograde amnesia, difficulty recognizing familiar individuals, and impaired reading ability. He was ultimately discharged to inpatient rehabilitation with recommendations for secondary stroke prevention.
Conclusion
AOP infarction is an uncommon and underdiagnosed cause of ischemic stroke, often presenting with altered mental status and ocular abnormalities. Its rarity, coupled with the limitations of early imaging, contributes to diagnostic delays and exclusion from thrombolytic therapy. This case underscores the importance of recognizing AOP infarction as a differential diagnosis in patients presenting with sudden neurological decline, particularly after non-neurological surgical procedures. Given the patient’s same-day surgery, anesthesia exposure, and cardiovascular risk factors, these elements may have played a role in precipitating the infarction.
Clinicians must maintain a high index of suspicion for AOP infarction in patients with acute unexplained neurological deterioration. Advanced imaging techniques, particularly diffusion-weighted MRI, are essential for early diagnosis and appropriate management. Increased awareness of this rare condition may facilitate earlier intervention and improve patient outcomes in similar cases of posterior circulation infarction.