Ann Rehabil Med.  2016 Aug;40(4):751-756. 10.5535/arm.2016.40.4.751.

Acute Pseudobulbar Palsy After Bilateral Paramedian Thalamic Infarction: A Case Report

• Lee HY
• Kim MJ
• Kim BR
• Koh SE
• Lee IS
• Lee J

• KMID: 2356663
• DOI: http://doi.org/10.5535/arm.2016.40.4.751

Abstract

Bilateral paramedian thalamic infarction is a rare subtype of stroke caused by occlusion of the artery of Percheron, an uncommon variant originating from one of the posterior cerebral arteries. This type of stroke has several major clinical presentations: altered mental status, behavioral amnestic impairment, aphasia or dysarthria, ocular movement disorders, motor deficits, cerebellar signs, and others. Few cases of bilateral paramedian thalamic infarction-related pseudobulbar palsy characterized by dysarthria, dysphagia, and facial and tongue weakness have been reported. We report here a rare case of acute severe pseudobulbar palsy as a manifestation of bilateral paramedian thalamic infarction.

Keyword

Pseudobulbar palsy; Thalamus; Infarction

MeSH Terms

Aphasia
Arteries
Deglutition Disorders
Dysarthria
Infarction*
Movement Disorders
Posterior Cerebral Artery
Pseudobulbar Palsy*
Stroke
Thalamus
Tongue

Figure

• 

  Fig. 1 Upward gaze limitation in nine diagnostic positions of gaze. When asked to look in the 9 diagnostic positions of gaze (up and to the right, up, up and to the left, right, straight ahead, left, down and to the right, down, and down and to the left) the upper gaze was limited (first row).

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  Fig. 2 Initial brain computed tomography (CT) angiography and magnetic resonance images. (A) Axial diffusion-weighted imaging sequences. (B) Apparent diffusion coefficient image. (C) Coronal T2 image showing an acute bilateral paramedian thalamic infarction (arrows). (D) CT angiography. (E) Magnified image of the basilar and posterior cerebral arteries demonstrating an unpaired thalamic perforating artery (arrowhead) arising from the proximal P1 segment of the left posterior cerebral artery supplying the bilateral thalami. (F) Axial T2 FLAIR image showing no midbrain lesion.

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  Fig. 3 Increased latencies for both posterior tibial nerves representing somatosensory dysfunction. When upper extremities were stimulated for somatosensory evoked potentials, both median nerves were within the normal range (A, B). However, increased latencies were observed for both posterior tibial nerves when the lower extremities were stimulated for somatosensory evoked potentials (C, D).

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  Fig. 4 Schematic representation of variations of the paramedian thalamic-mesencephalic arterial supply according to Percheron. (A) In the most common variation, many small perforating arteries arise from the P1 segment of the PCA. (B) The AOP is a single perforating blood vessel arising from a P1 segment. (C) In the third variant, an arcade of perforating branches arises from an artery bridging the P1 segments of both PCAs. PCoA, posterior communicating artery; PCA, posterior cerebral artery; BA, basilar artery; SCA, superior cerebellar artery; AOP, artery of Percheron.

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