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

Prasanna Venkatesan¹, R Balakrishnan¹, K Ramadoss¹, Rajesh Shankar Iyer²,  
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

Correspondence Address:
Rajesh Shankar Iyer
Department of Neurology, KG Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu
India

Full Text

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}

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}

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