A 58-year-old female presented with sudden onset blurred vision and right-sided weakness and was found to have an acute left thalamic infarction; imaging showed no vascular abnormalities but she had an incidental finding of a possible atrial septal defect; she was treated with tPA and made a full recovery with no residual deficits.

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

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. CASE
PMH/PSH:
1. Infiltrating DCIS s/p lumpectomy/radiation – 2006
2. Insomnia – 2006
3. Reported incidental heart murmur – 2007
Social Hx:
Tob – negative
ETOH – socially
Illicits – negative
Married
Speech/Language Pathologist
Family Hx:
CAD, Breast Cancer, Brother w/ brain aneurysm

4. CASE
Medications:
Lorazepam prn insomnia
Allergies:
NKDA

5. CASE
Physical Exam:
VS: HR – 73 BP – 154/83 R – 14 O2- 98% RA
General Medical Exam – normal
Neurologic 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. CASE
Hospital Course:
Arrival – 9:30 AM
Examination – 10:05 AM
Pt 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. CASE
Arrival 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/l
upward gaze palsy
Neurologic Exam -8/12/2012
-GCS – 15 (E-4,V-5,M-6), NIHSS – 0, b/l upper gaze
palsy (R>L) w/ binocular upper gaze diplopia, remainder of
neurologic exam normal.
Neurologic Exam -8/12/2012
- Neurologic exam within normal limits w/ no residual deficits

8. CASE
Labs:
CBC – normal
BMP – normal
PT/INR – 10.8/1.1
Cholesterol – LDL reported as 154
HgbA1c – 5.3

9. CASE
Radiology:

10. CASE
Radiology Cont:
MRI Brain – acute L thalamic infarction
CTA – No stenosis in the anterior or the posterior
circulation, small nodule L lobe of thyroid
TTE – evidence of ? ASD

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)

13. Artery of Percheron
• Paramedian A.

14. Thalamic Infarction Localization

15. 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

16. 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

17. 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

18. 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 dysthymia's

19. Thalamic Infarction Localization

20. Case
Plan:
-Pt d/c on zocor 40 mg daily and ASA 325
mg
-Presented to Neurology Clinic 8/22/2012 pt
continues to be asymptomatic
-Cont ASA and statin for now, 30 day ECAT
monitor, TEE