Case Report http://doi.org/10.18231/j.ijn.2019.013 IP Indian Journal of Neurosciences, April-June, 2019;5(2):91-94 91 A case of rare stroke syndrome admitted in intensive care unit - Artery of Percheron infarction K.Gunasekaran 1* , S. Sivakumar 2 , K.Thiruvarutchelvan 3 1 Assistant Professor, 2 Professor and HOD, 3 Professor, Dept. of Neurology, Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India *Corresponding Author: K.Gunasekaran Email: drgunasekaranneuro@gmail.com Abstract Artery of Percheron is a rare anatomical variant of thalamic vascular supply. Stroke involving this vasculature is an uncommon event. Occlusion of this vessel produces a peculiar pattern in the form of bilateral thalamic infarcts with or without midbrain infarction. This results in variable clinical features ranging from somnolence or altered sensorium to coma in affected individuals, accompanied by characteristic neurological manifestations. Diagnosis of artery of Percheron infarction at the initial presentation may be difficult as it is infrequent and early neuroimaging studies may be negative. Here we report a patient, a case of AOP infarct whose MRI brain and clinical picture demonstrated the characteristic features. Keywords: Artery of Percheron, Ischemic stroke, Thalamus, Magnetic resonance Imaging. Introduction Among the various posterior circulation stroke syndromes, artery of Percheron (AOP) infarction is a rare presentation. Occlusion of AOP results in characteristic neurological signs and symptoms as there is impairment of perfusion occurs in thalamus alone or thalamus with midbrain bilaterally. Among the cerebral ischemic infarcts, AOP occlusion constitutes 0.1% to 0.3% of cases. 1 In ischemic infarct involving thalamus, AOP obstruction constitutes 22% to 35% of cases. 2 Early diagnosis of this stroke may be difficult because it is an uncommon one and neuroimaging with computed tomography (CT) scan or magnetic resonance image (MRI) scan may not be contributory at initial stage. More over some other posterior circulation stroke syndromes may manifest similar features which will result in diagnostic dilemma. Here we describe a patient, who was admitted in our ICU with features of posterior circulation stroke in whom diagnosis of this rare condition was made out by characteristic MRI features. Case Report Mrs.V, a 61 years old woman, admitted in ICU of our hospital with complaints of drowsiness since the morning. Patient was apparently normal previous night, next day morning found to be drowsy and responding poorly to calls. Patient was a known hypertensive, irregularly on drugs and not a diabetic. There was no history of injury, fever, recurrent vomiting or seizure. There were no similar symptoms or any neurological illness in the past. On examination, her vital signs were: BP: 150/90 mmhg, PR: 88/min. Respiration and temperature were normal. Examination of higher mental function: patient was confused, stuporous but arousable and going for sleepy state frequently. Word output was less with slurring of speech noted. There was no aggressive behaviour or hallucinations. Cranial nerves examination showed bilateral complete ptosis with bilateral external ophthalmoplegia. Except minimal abduction in left eye all other movements were absent. Oculocephalic reflex was absent. Vertical gaze was absent. Both sides pupils were 2.5mm, sluggishly reacting to light. Other cranial nerves were normal. Palatal movements were normal. Spinomotor system examination: patient was able to move all the four limbs, tone in limbs were normal and deep tendon reflexes were retained. Bilateral plantar reflexes were mute. Sensory system could not be tested. Cerebellar system: though the patient was able to walk with support, gait ataxia was noted. Other systems were clinically normal. With these clinical features, possible diagnosis of stroke involving the posterior circulation was made out and management was initiated with basic and supportive care. Her investigations were as follows: complete hemogram, renal function tests and blood glucose were within normal limits. ECG showed no significant changes. MRI brain T2/FLAIR (fluid-attenuated inversion recovery) sequences showed hyperintense signal in bilateral paramedian region of thalamus and rostral part of midbrain (Fig. 1, 2 & 3) with diffusion restriction in same regions in DWI (diffusion - weighted images) (Fig. 4), which were in favour of acute infarct. Also the characteristic ‘V’ sign (Fig. 5, 6 &7) was present. MR cerebral angiography (Fig. 8) and venography were unremarkable. Based on these clinical picture and neuroimaging findings diagnosis of AOP infarct was made and treated accordingly. Fig. 1: T2 FLAIR axial view bilateral thalamic infarct