Presentation
Found on floor. Unequal pupils in A&E. CT head showed left thalamic lacunar infarct. No upward or downward gaze, ataxia, reduced GCS.
Patient Data
The symmetrical areas of restricted diffusion and hyperintense appearance on FLAIR images denote bilateral paramedian thalamic and midbrain infarctions.
Previous non-contrast CT demonstrates left thalamic infarction. The rest of the infarcted areas can only be suspected retrospectively.
Case Discussion
The pathognomonic appearance of this special type posterior circulation infarction can be explained by the presence of congenital variant of artery of Percheron.
The findings are best seen on FLAIR and DWI sequences, while CT might miss or underestimate the infarct. The V-shaped hyperintensity due to midbrain infarct is congruent with the ataxia and oculomotor symptoms.
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