Thalamic infarction

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Thalamic infarction

  1. 1. THALAMIC VASCULAR SYNDROMES Chris Robinson, DO Deparment of Neurology Loyola University Medical Center 2012.
  2. 2. CASE• 58 y/o female driving w/ husband @ 9:30 AM w/ sudden onset blurred vision and difficulty focusing.• 5 min later w/ R facial droop, somnolence, aphasia and R hemiparesis• Present to OSH at 10:05 AM
  3. 3. CASEPMH/PSH:1. Infiltrating DCIS s/p lumpectomy/radiation – 20062. Insomnia – 20063. Reported incidental heart murmur – 2007Social Hx:Tob – negativeETOH – sociallyIllicits – negativeMarriedSpeech/Language PathologistFamily Hx:CAD, Breast Cancer, Brother w/ brain aneurysm
  4. 4. CASEMedications:Lorazepam prn insomniaAllergies:NKDA
  5. 5. CASEPhysical Exam:VS: HR – 73 BP – 154/83 R – 14 O2- 98% RAGeneral Medical Exam – normalNeurologic Exam- NIHSS – 12- 1- partial gaze palsy, 3 – b/l hemianopsia, 2 – partial facial weakness, 1 – one limb ataxia, 2- severe sensory loss, 1 – mild aphasia, 1 – mild dysarthria, 1- mild extinction- Sx – binocular vertical diplopia, blurred vision, R facial droop, and R sided weakness- Pt recorded as alert, oriented, comprehensive, and w/out focal motor weakness
  6. 6. CASEHospital Course:Arrival – 9:30 AMExamination – 10:05 AMPt w/ objective evidence of stroke and negative CTT for bleed recieves IV Alteplase at 11:15 am and is transferred to UMASS for neuro ICU care.
  7. 7. CASEArrival at UMASS – 8/11/2012-NIHSS of 6 on arrival - records of exam not received –known at that time pt had R sided facial droop and b/lupward gaze palsyNeurologic Exam -8/12/2012-GCS – 15 (E-4,V-5,M-6), NIHSS – 0, b/l upper gazepalsy (R>L) w/ binocular upper gaze diplopia, remainder ofneurologic exam normal.Neurologic Exam -8/12/2012- Neurologic exam within normal limits w/ no residual deficits
  8. 8. CASELabs:CBC – normalBMP – normalPT/INR – 10.8/1.1Cholesterol – LDL reported as 154HgbA1c – 5.3
  9. 9. CASERadiology:
  10. 10. CASERadiology Cont:MRI Brain – acute L thalamic infarctionCTA – No stenosis in the anterior or the posteriorcirculation, small nodule L lobe of thyroidTTE – evidence of ? ASD
  11. 11. Thalamic Blood Supply• 4 Major Vacular Territories 1. Tuberothalamic or Polar Artery (PCOM) 2. Paramedian (Basilar Communicating Artery 3. Inferolateral or Thalamogeniculate (PCA) 4. Posterior Choroidal (PCA)
  12. 12. Artery of Percheron• Paramedian A.
  13. 13. Thalamic Infarction Localization
  14. 14. Posterolateral Inarction• Occlusion of thalamogeniculate a.• P2 segment of PCA• 3 common clinical syndromes 1. Pure Sensory 2. Sensorimotor 3. Dejerine-Roussy - contralateral sensory, thalamic pain of involved side, vasomotor disturbance, transient contralateral hemiparesis, and mild hyperkinetic disturbances
  15. 15. Anterior Infarction• Occlusion of polar or turberothalamic a.• Branch of PCOM• Clinical Manifestations - Alteration in consciousness, abulia, disorientation, personality disturbances, visual field deficits L sided – thalamic aphasia R sided – hemineglect, alien hand
  16. 16. Paramedian Infarction• Paramedian a. -• Branch of basilar communication a. – Basilar a. prior to ostium of PCOM• Clinical Manifestations – somnolence, memory loss, mood disturbances, vertical gaze abnormalities• Can be b/l – artery of percheron – hypersomnolence and marked memory impairment
  17. 17. Dorsal Infarction• Posterior Choroidal a.• Branch of P2 segment of PCA• Clinical Manifestations – homonymous quadrantanopia or homonymous horizontal sectoranopias – If pulvinar affected can have aphasia or cardiac dysthymias
  18. 18. Thalamic Infarction Localization
  19. 19. CasePlan:-Pt d/c on zocor 40 mg daily and ASA 325mg-Presented to Neurology Clinic 8/22/2012 ptcontinues to be asymptomatic-Cont ASA and statin for now, 30 day ECATmonitor, TEE

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