Bilateral Thalamic and Midbrain Stroke Due to Occlusion of the Percheron Artery: Acute-Phase Endovascular Treatment with Local Intra-arterial Fibrinolysis and Favorable Outcome

Artery of Percheron infarction, a rare but critical cerebrovascular event, poses unique diagnostic and therapeutic challenges. This condition, characterized by bilateral paramedian thalamic infarction with or without midbrain involvement due to occlusion of the artery of Percheron, an anatomical variant, requires a comprehensive understanding of its clinical presentation, imaging features, and the intricacies of treatment strategies. Because artery of Percheron infarction can lead to significant morbidity and mortality, a multidisciplinary approach is essential to ensure accurate diagnosis, prompt intervention, and optimal patient outcomes. A 38-year-old female patient was admitted to the emergency department of our hospital with complex oculomotor dysfunction over a 2-hour period. On clinical examination, the patient’s level of consciousness decreased and she became unresponsive. As a result, the patient was intubated. Brain MRI revealed acute ischemia involving the paramedian thalamic region and rostral midbrain bilaterally. Subsequent digital subtraction angiography confirmed the occlusion of a Percheron artery arising from the P1 segment of the right posterior cerebral artery. Endovascular intra-arterial selective thrombolysis was then performed under general anesthesia, resulting in complete recanalization. Subsequent MRI scans showed a reduction of ischemic changes within the right thalamus and midbrain; however, the size of the lesion located in the left thalamus increased. There was a marked improvement in the patient’s clinical symptoms over the course of the hospitalization. After identification of a patent foramen ovale (PFO), oral anticoagulation with phenprocoumon was initiated and endovascular closure of the PFO was performed within 6 weeks. This case highlights the diagnostic subtleties, management challenges, and therapeutic options in patients presenting with artery of Percheron infarction.