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NEUROIMAGE
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 115-116

Heart appearance sign in pontine stroke: A result of bilateral infarction due to small vessel disease


1 Department of Neurology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Neurology, KG Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu, India

Date of Web Publication7-Mar-2014

Correspondence Address:
Rajesh Shankar Iyer
Department of Neurology, KG Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.128365

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How to cite this article:
Venkatesan P, Balakrishnan R, Ramadoss K, Iyer RS. Heart appearance sign in pontine stroke: A result of bilateral infarction due to small vessel disease. Neurol India 2014;62:115-6

How to cite this URL:
Venkatesan P, Balakrishnan R, Ramadoss K, Iyer RS. Heart appearance sign in pontine stroke: A result of bilateral infarction due to small vessel disease. Neurol India [serial online] 2014 [cited 2019 Nov 12];62:115-6. Available from: http://www.neurologyindia.com/text.asp?2014/62/1/115/128365


We describe an interesting appearance of pontine infarction in the shape of heart and discuss the cause.

A 53-year-old diabetic and hypertensive suddenly developed vertigo and slurring of speech. He was drowsy and unresponsive to pain. Doll's eye reflex was absent and plantar was bilaterally extensor. Magnetic resonance imaging of brain revealed bilateral pontine infarction with the characteristic "heart appearance" on axial images [Figure 1]a-c. Magnetic resonance-angiography showed features of atherosclerotic vertebral and basilar artery disease [Figure 1]d. He remained tetraplegic despite good supportive care.
Figure 1: Magnetic resonance imaging brain images showing acute pontine infarction with the characteristic "heart appearance" seen on diffusionweighted image (a) and T2-weighted images (c). Corresponding apparent diffusion coefficient map shows restricted diffusion in the same territories (b). Magnetic resonance angiography at the time of infarct shows
diffuse atherosclerotic disease of the vertebral and basilar arteries (d)


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The heart appearance sign is well-described in bilateral medial medullary infarction. [1] Only one report is available describing such an appearance in pontine infarction. [2] In a review of 150 cases of pontine infarction, Kumral et al. reported 14 cases (11%) of bilateral pontine infarction. [3] Seven of them represented schematically in their paper had the heart appearance though they never mentioned this. The blood supply of pons and the heart appearance is depicted schematically in [Figure 2]. Pons is supplied by the basilar artery through its three branches. The paramedian arteries supply the antero-medial arterial territory while the short circumferential branches supply the antero-lateral pons. The long circumferential branches namely anterior inferior cerebellar artery and superior cerebellar artery supply the lateral territory. For the heart appearance to occur, there should be bilateral involvement of the antero-medial and the antero-lateral arterial territories sparing the lateral territories. This may happen with atherothrombotic disease of the basilar artery selectively involving the bilateral paramedian and short circumferential branches and sparing the long circumferential branches.
Figure 2: Schematic diagram showing the three arterial territories of pons and the heart appearance arising out of involvement of the anteromedial and antero-lateral arterial territories. CST - Corticospinal tract, ML - Medial leminiscus, SON - Superior olivary nucleus, MLF - Medial longitudinal fasciculus

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 » References Top

1.Krishnan M, Rajan P, Kesavadas C, Iyer RS. The ′heart appearance′ sign in MRI in bilateral medial medullary infarction. Postgrad Med J 2011;87:156-7.  Back to cited text no. 1
    
2.Ishizawa K, Ninomiya M, Nakazato Y, Yamamoto T, Araki N. "Heart appearance" infarction of the pons: A case report. Case Rep Radiol 2012;2012:690903.  Back to cited text no. 2
    
3.Kumral E, Bayülkem G, Evyapan D. Clinical spectrum of pontine infarction. Clinical-MRI correlations. J Neurol 2002;249:1659-70.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]

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