2024 American Academy of Neurology Abstract Website

Objective:

The timely diagnosis of complex strokes is vital for patient morbidity and mortality. The artery of Percheron (AOP) is an uncommon anatomical variant that branches off the P1 portion of the posterior cerebral artery and supplies the bilateral paramedian thalamus with varying midbrain distributions. Occlusion of this vascular anomaly is rare and frequently provides a diagnostic dilemma due to the varying presentation and often delayed imaging findings. This often leads to poor outcomes, such as hypersomnia, autonomic dysregulation, and comatose due to an increasing degree of thalamic infarction. This article aims to increase the recognition of this syndrome to allow for expedited treatment.

Background:

Previous studies indicate a prevalence of 4-12% for AOP within the population, with its occlusion accounting for only 0.1-2% of all strokes. The most common manifestations following AOP infarction encompass vertical eye movement abnormalities, memory/cognitive impairment, and altered mental status. However, the neuro-ophthalmic manifestations show substantial variability, potentially complicating the diagnosis. Among the most exceptional presentations of this syndrome is complete bilateral ophthalmoplegia, characterized by full ptosis accompanied by vertical and horizontal gaze paralysis.

Design/Methods:

Results:

This case highlights a patient with many cardiovascular risk factors who presented with hypersomnolence, ataxia, mydriasis, convergence-retraction nystagmus, and the rare clinical finding of complete, bilateral ophthalmoplegia. Imaging studies revealed acute, especially pronounced bilateral paramedian thalamic lesions, along with bilateral rostral midbrain and left inferior cerebellar lesions that are most consistent with an occlusion of the artery of Percheron. Management was limited by timing of patient presentation therefore symptomatic treatment was initiated. Due to the extent of the injury, the patient’s recovery was limited despite extensive occupational and physical therapies.

Conclusions:

This presentation emphasizes difficulties that result from variable and delayed patient presentation to enhance prompt recognition to improve patient outcomes.