THALAMIC VASCULAR SYNDROMES Chris Robinson, DO Deparment of Neurology Loyola University Medical Center 2012.
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
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
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.
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
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
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
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
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