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Table of Contents    
NEUROIMAGES
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 927

V-shaped MRI change in the midbrain of a patient with artery of Percheron infarction


Department of Neurology, Nagano Red Cross Hospital, Wakasato, Nagano, Japan

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Yuya Kobayashi
Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263240

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How to cite this article:
Kobayashi Y, Yahikozawa H, Sato S. V-shaped MRI change in the midbrain of a patient with artery of Percheron infarction. Neurol India 2019;67:927

How to cite this URL:
Kobayashi Y, Yahikozawa H, Sato S. V-shaped MRI change in the midbrain of a patient with artery of Percheron infarction. Neurol India [serial online] 2019 [cited 2019 Aug 24];67:927. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/927/263240




A 68-year old man presented with acute onset bilateral ptosis [Figure 1]a. He was taking apixaban and cilostazol for atrial fibrillation and angina pectoris. Upon admission, he was alert, and his pupils were dilated 5 mm and unreactive to light. He developed paralysis of eye movements, except for lateral rectus, consistent with bilateral oculomotor paralysis [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g. In addition, the patient had left hemianopsia. He did not have quadriplegia or any other neurological symptoms; these symptoms developed 12 h before admission and never improved. Anti-acetylcholine receptor antibodies were negative, whereas serum vitamin B1 and B12 levels were normal. Furthermore, diffusion-weighted magnetic resonance imaging (MRI) revealed infarction of bilateral thalami, rostral midbrain, and right occipital lobe [Figure 1]h and [Figure 1]i. He was diagnosed with artery of Percheron (AOP) and posterior cerebral artery (PCA) infarction. Bilateral paramedian thalamic stroke is characterized by vertical gaze palsy, memory impairment, and coma;[1] however, our patient developed only bilateral oculomotor nerve paralysis. Moreover, cerebral peduncle infarction affected only the oculomotor nerve emerging from the brainstem. The nearby oculomotor nucleus and interstitial nucleus of Cajar remained unaffected. The thalami and midbrain are supplied by several small arterial branches exhibiting significant variability. AOP is an uncommon variant arising from PCA supplying bilateral thalami with rostral midbrain.[1] A study reported that AOP infarction occurred in only 0.6% of 2750 patients with ischemic stroke,[2] and AOP is rarely visualized after infarction.[1],[3],[4],[5] Our patient demonstrated a typical V-shaped MRI change in the midbrain, which was reported in 67% of patients with AOP infarction.[1]
Figure 1: (a) The patient was unable to open his eyes. (b-f) The eye movement was possible only for adduction. (g) The pupils were unreactive to light. (h and i) Diffusion-weighted MRI revealing infarction of the thalamus and anterior cerebral peduncle bilaterally and of the right occipital lobe. The V-shaped hyperintense signal intensity in the midbrain is characteristic

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  References Top

1.
Lazzaro NA, Wright B, Castillo M, Fischbein NJ, Glastonbury CM, Hildenbrand PG, et al. Artery of percheron infarction: Imaging patterns and clinical spectrum. Am J Neuroradiol 2010;31:1283-9.  Back to cited text no. 1
    
2.
Kumral E, Evyapan D, Balkir K, Kutluhan S. Bilateral thalamic infarction. Clinical, etiological and MRI correlates. Acta Neurol Scand 2001;103:35-42.  Back to cited text no. 2
    
3.
Lamot U, Ribaric I, Popovic KS. Artery of Percheron infarction: Review of literature with a case report. Radiol Oncol 2015;49:141-6.  Back to cited text no. 3
    
4.
Aaron S, Mani S, Prabhakar AT, Karthik K, Patil AB, Babu PS, et al. Stuck with a drowsy patient, evoke the Percheron. Neurol India 2015;63:542-7.  Back to cited text no. 4
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5.
Bhattacharjee S, Ng KL. Vertical gaze palsy due to acute bilateral thalamic infarct without midbrain ischemia. Neurol India 2017;65:919-20.  Back to cited text no. 5
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