Presentation is loading. Please wait.

Presentation is loading. Please wait.

Unusual Brain Lesion with a Usual Cause Ryan Frederiksen MD, Sean Snodgress MD, Benjamin Kianmahd MSIV Department of Radiology Santa Barbara Cottage Hospital.

Similar presentations


Presentation on theme: "Unusual Brain Lesion with a Usual Cause Ryan Frederiksen MD, Sean Snodgress MD, Benjamin Kianmahd MSIV Department of Radiology Santa Barbara Cottage Hospital."— Presentation transcript:

1 Unusual Brain Lesion with a Usual Cause Ryan Frederiksen MD, Sean Snodgress MD, Benjamin Kianmahd MSIV Department of Radiology Santa Barbara Cottage Hospital

2 Clinical History: Patient A 36 year old right handed male with no prior medical history 36 year old right handed male with no prior medical history Found unresponsive at gas station Found unresponsive at gas station No history of drug abuse, trauma, hypertension, hypercoaguable state or significant family history No history of drug abuse, trauma, hypertension, hypercoaguable state or significant family history Physical Exam: GCS 8 Physical Exam: GCS 8 Labs: within normal limits except for BS > 500 Labs: within normal limits except for BS > 500

3 Imaging: Patient A Head CT Day #1 Initial Head CT was normal Initial Head CT Day 1: Normal.

4 Imaging: Patient A MRI Day 2: Bilateral thalamic infarcts. MRI DWIMRI ADC

5 Imaging: Patient A Head CT Day #1 Initial Head CT was normal Head CTA Day 2: Bilateral thalamic infarcts; CTA portion was normal.

6 Imaging: Patient A Head CT Day #1 Initial Head CT was normal Head CT Day 3: Hemorrhagic thalamic infarcts.

7 Clinical History: Patient B 85 year old male with history of hypertension and GERD 85 year old male with history of hypertension and GERD Presented to PMD with 5 day history of ataxia and double vision Presented to PMD with 5 day history of ataxia and double vision Physical Exam: leftward ataxic gait, bilateral horizontal nystagmus, no focal sensory or motor deficits Physical Exam: leftward ataxic gait, bilateral horizontal nystagmus, no focal sensory or motor deficits Labs: LDL 151 Labs: LDL 151

8 Imaging: Patient B MRI DWI MRI FLAIR MRI Day 5 of Symptoms: Bilateral thalamic infarcts.

9 What’s the diagnosis?

10 Bilateral Thalamic Infarcts Broad differential diagnosis Broad differential diagnosis Venous occlusion: vein of Galen, straight sinus, bilateral internal cerebral veins Venous occlusion: vein of Galen, straight sinus, bilateral internal cerebral veins Diffuse astrocytoma Diffuse astrocytoma ADEM ADEM Arterial ischemia: artery of Percheron Arterial ischemia: artery of Percheron

11 Discussion: Background These two cases demonstrate an anatomic variant These two cases demonstrate an anatomic variant Occlusion of the artery of Percheron results in a characteristic pattern of infarct Occlusion of the artery of Percheron results in a characteristic pattern of infarct Infarct of the bilateral paramedian thalamus with or without midbrain involvement Infarct of the bilateral paramedian thalamus with or without midbrain involvement

12 Discussion: Background The thalamus’ blood supply is usually supplied by: The thalamus’ blood supply is usually supplied by: multiple perforator vessesls originating from the posterior communicating artery multiple perforator vessesls originating from the posterior communicating artery the P1 and P2 segments of the posterior cerebral arteries the P1 and P2 segments of the posterior cerebral arteries

13 Discussion: Background The anterior region is supplied by The anterior region is supplied by the polar (thalamotuberal) arteries, arising from the posterior communicating artery the polar (thalamotuberal) arteries, arising from the posterior communicating artery The paramedian region is supplied by The paramedian region is supplied by the paramedian (thalamoperforating) arteries which originate from the P1 segment of the posterior cerebral artery the paramedian (thalamoperforating) arteries which originate from the P1 segment of the posterior cerebral artery The inferolateral region is supplied by The inferolateral region is supplied by the thalamogeniculate arteries which arise from the P2 segment of the posterior cerebral artery the thalamogeniculate arteries which arise from the P2 segment of the posterior cerebral artery The posterior region is supplied by The posterior region is supplied by the posterior choroidal arteries, which originate from the P2 segment of the posterior cerebral artery. the posterior choroidal arteries, which originate from the P2 segment of the posterior cerebral artery.

14 Discussion: Background The paramedian arteries supplying the thalamus and midbrain exhibit the greatest amount of variability The paramedian arteries supplying the thalamus and midbrain exhibit the greatest amount of variability According to Percheron, there are three variations According to Percheron, there are three variations This exhibit focuses on a specific anatomic variant of the paramedian arteries, known as the Artery of Percheron This exhibit focuses on a specific anatomic variant of the paramedian arteries, known as the Artery of Percheron

15 Discussion: Paramedian Thalamic Blood Supply Variations A.Many perforating arteries from the P1 segment of the PCA; the most common B.A single artery from the P1 segment; the artery of Perheron C.An arcade of perforating arteries from both PCAs 2

16 Discussion: Artery of Percheron A single dominant thalamoperforating artery supplying the bilateral medial thalami with variable contribution to the rostral midbrain 3

17 Discussion Common physical exam findings Common physical exam findings Oculomotor palsy (76% of patients) Oculomotor palsy (76% of patients) Mild gait ataxia (67%) Mild gait ataxia (67%) Deficits of attention (63%) Deficits of attention (63%) Fluency and error control (59%) Fluency and error control (59%) Learning and memory (67%) Learning and memory (67%) Behavior (67%) Behavior (67%)

18 Discussion One retrospective study identified four patterns of artery of Percheron infarcts One retrospective study identified four patterns of artery of Percheron infarcts Bilateral paramedian thalamic with midbrain (43%) Bilateral paramedian thalamic with midbrain (43%) Bilateral paramedian thalamic without midbrain (38%) Bilateral paramedian thalamic without midbrain (38%) Bilateral paramedian thalamic with anterior thalamus and midbrain (14%) Bilateral paramedian thalamic with anterior thalamus and midbrain (14%) Bilateral paramedian thalamic with anterior thalamus without midbrain (5%) Bilateral paramedian thalamic with anterior thalamus without midbrain (5%)

19 Conclusion The artery of Percheron is one of the few examples where a cerebral blood vessel supplies structures on both sides of the midline!

20 References Lazzaro NA, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol Aug;31(7): Epub 2010 Mar 18. Lazzaro NA, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol Aug;31(7): Epub 2010 Mar 18. Matheus MG, et al. Imaging of acute bilateral paramedian thalamic and mesencephalic infarcts. AJNR Am J Neuroradiol Nov- Dec;24(10): Matheus MG, et al. Imaging of acute bilateral paramedian thalamic and mesencephalic infarcts. AJNR Am J Neuroradiol Nov- Dec;24(10): Mujeeb, S, et al. Symmetric bilateral thalamic infarcts: a rare complication of cardiac catheterization. The Internet Journal of Cardiology Vol 7; No 1. Mujeeb, S, et al. Symmetric bilateral thalamic infarcts: a rare complication of cardiac catheterization. The Internet Journal of Cardiology Vol 7; No 1.


Download ppt "Unusual Brain Lesion with a Usual Cause Ryan Frederiksen MD, Sean Snodgress MD, Benjamin Kianmahd MSIV Department of Radiology Santa Barbara Cottage Hospital."

Similar presentations


Ads by Google