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Unusual Brain Lesion with a Usual Cause

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1 Unusual Brain Lesion with a Usual Cause
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Unusual Brain Lesion with a Usual Cause Ryan Frederiksen MD, Sean Snodgress MD, Benjamin Kianmahd MSIV Department of Radiology Santa Barbara Cottage Hospital Presented at LARS Midwinter 2011

2 Clinical History: Patient A
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Clinical History: Patient A 36 year old right handed male with no prior medical history Found unresponsive at gas station No history of drug abuse, trauma, hypertension, hypercoaguable state or significant family history Physical Exam: GCS 8 Labs: within normal limits except for BS > 500 Presented at LARS Midwinter 2011

3 Head CT Day #1 Initial Head CT was normal
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Imaging: Patient A Initial Head CT Day 1: Normal. Head CT Day #1 Initial Head CT was normal Presented at LARS Midwinter 2011

4 MRI Day 2: Bilateral thalamic infarcts.
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Imaging: Patient A MRI DWI MRI ADC MRI Day 2: Bilateral thalamic infarcts. Presented at LARS Midwinter 2011

5 Head CT Day #1 Initial Head CT was normal
Imaging: Patient A R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Head CTA Day 2: Bilateral thalamic infarcts; CTA portion was normal. Head CT Day #1 Initial Head CT was normal Presented at LARS Midwinter 2011

6 Head CT Day #1 Initial Head CT was normal
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Imaging: Patient A Head CT Day 3: Hemorrhagic thalamic infarcts. Head CT Day #1 Initial Head CT was normal Presented at LARS Midwinter 2011

7 Clinical History: Patient B
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Clinical History: Patient B 85 year old male with history of hypertension and GERD 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 Labs: LDL 151 Presented at LARS Midwinter 2011

8 Bilateral thalamic infarcts.
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Imaging: Patient B MRI FLAIR MRI DWI MRI Day 5 of Symptoms: Bilateral thalamic infarcts. Presented at LARS Midwinter 2011

9 R. Frederiksen, S. Snodgress, B
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital What’s the diagnosis? Presented at LARS Midwinter 2011

10 Bilateral Thalamic Infarcts
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Bilateral Thalamic Infarcts Broad differential diagnosis Venous occlusion: vein of Galen, straight sinus, bilateral internal cerebral veins Diffuse astrocytoma ADEM Arterial ischemia: artery of Percheron Presented at LARS Midwinter 2011

11 Discussion: Background
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Background These two cases demonstrate an anatomic variant Occlusion of the artery of Percheron results in a characteristic pattern of infarct Infarct of the bilateral paramedian thalamus with or without midbrain involvement Presented at LARS Midwinter 2011

12 Discussion: Background
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Background The thalamus’ blood supply is usually supplied by: multiple perforator vessesls originating from the posterior communicating artery the P1 and P2 segments of the posterior cerebral arteries Presented at LARS Midwinter 2011

13 Discussion: Background
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Background The anterior region is supplied by the polar (thalamotuberal) arteries, arising from the posterior communicating artery The paramedian region is supplied by the paramedian (thalamoperforating) arteries which originate from the P1 segment of the posterior cerebral artery The inferolateral region is supplied by the thalamogeniculate arteries which arise from the P2 segment of the posterior cerebral artery The posterior region is supplied by the posterior choroidal arteries, which originate from the P2 segment of the posterior cerebral artery. Presented at LARS Midwinter 2011

14 Discussion: Background
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Background The paramedian arteries supplying the thalamus and midbrain exhibit the greatest amount of variability 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 Presented at LARS Midwinter 2011

15 Discussion: Paramedian Thalamic Blood Supply Variations
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Paramedian Thalamic Blood Supply Variations 2 Many perforating arteries from the P1 segment of the PCA; the most common A single artery from the P1 segment; the artery of Perheron An arcade of perforating arteries from both PCAs Presented at LARS Midwinter 2011

16 Discussion: Artery of Percheron
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion: Artery of Percheron 3 A single dominant thalamoperforating artery supplying the bilateral medial thalami with variable contribution to the rostral midbrain Presented at LARS Midwinter 2011

17 Discussion Common physical exam findings
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion Common physical exam findings Oculomotor palsy (76% of patients) Mild gait ataxia (67%) Deficits of attention (63%) Fluency and error control (59%) Learning and memory (67%) Behavior (67%) Presented at LARS Midwinter 2011

18 R. Frederiksen, S. Snodgress, B
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Discussion One retrospective study identified four patterns of artery of Percheron infarcts Bilateral paramedian thalamic with midbrain (43%) Bilateral paramedian thalamic without midbrain (38%) Bilateral paramedian thalamic with anterior thalamus and midbrain (14%) Bilateral paramedian thalamic with anterior thalamus without midbrain (5%) Presented at LARS Midwinter 2011

19 R. Frederiksen, S. Snodgress, B
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital Conclusion The artery of Percheron is one of the few examples where a cerebral blood vessel supplies structures on both sides of the midline! Presented at LARS Midwinter 2011

20 R. Frederiksen, S. Snodgress, B
R. Frederiksen, S. Snodgress, B. Kianmahd Santa Barbara Cottage Hospital 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. 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. Presented at LARS Midwinter 2011

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