ARTICLE IN PRESS

CLINICAL COMMUNICATION TO THE EDITOR

Bilateral Paramedian Thalamic Infarct

To the Editor:

An 81-year-old man with hypertension was admitted to our

hospital because of a 2-day history of impaired conscious-
ness. The patient's family doctor had examined him a day
prior to his hospitalization, and suspected that he was
experiencing hypoglycemic coma. He was treated with
intravenous glucose, which showed no effect. At admission,
his Glasgow Coma Scale score was 8 and body temperature
was 36.4˚C. Owing to his impaired consciousness, thorough
neurological evaluation was difficult. Although he did not
have unequal pupils, he moved all his extremities in
response to painful stimuli. On the basis of his laboratory
test results, hypoglycemic coma, as well as other possible
metabolic, infective, toxic, and endocrine etiologies, as
causes of consciousness disturbance, were excluded. He Figure Diffusion-weighted magnetic resonance image
showing high signal intensity in the axial plane within
underwent computed tomography of the head, which
the bilateral medial inferior of the thalamus.
showed hypodensity within the bilateral thalamus, bilateral
cerebellar hemispheres, right putamen, and cerebral cortex
of the bilateral frontal lobes. At first, the findings of the
thalamus were considered to indicate old infarcts. Addition-
impairment.1 The artery of Percheron is an uncommon ana-
ally, he underwent magnetic resonance imaging, which
tomic variant, and this single dominant thalamoperforating
revealed hyperintensity on diffusion-weighted images and
artery supplies blood to the bilateral paramedian thalamus
hypointensity on apparent diffusion coefficient images
with or without contribution to the midbrain.2 Therefore,
within the bilateral thalamic nuclei, indicating acute ische-
the occlusion of this artery likely results in a bilateral tha-
mic stroke (Figure). Consequently, he was diagnosed with
lamic infarct. In this case, the artery of Percheron was not
acute bilateral paramedian thalamic infarct as a cause of his
detected on magnetic resonance angiography. However, it
consciousness disturbance and intravenous thrombolysis
may be speculated that detecting this artery, especially after
therapy was initiated immediately. His consciousness dis-
the infarct, can be difficult. It is hypothesized that the para-
turbance gradually improved after treatment; however, he
median thalamus has 2 important roles: maintaining wake-
persisted to be somnolent, with variable Glasgow Coma
fulness and promoting non-rapid eye movement sleep.3
Scale scores from 8 to 13 during hospitalization, and he
Therefore, paramedian thalamic infarcts can cause sleep
demonstrated disorientation in time and place. He could not
disturbance, resulting in hypersomnia. The patient had no
be discharged home and was transferred to the sanatorium.
gaze palsy, but his altered consciousness, which presented
The bilateral paramedian thalamic infarct is an unusual
with symptoms of hypersomnia throughout the day and
and rare type of ischemic stroke, which is characterized by
night, was consistent as a typical feature of this condition.
altered consciousness, vertical gaze palsy, and cognitive
Careful observation, as well as profound knowledge about
Funding: None.
the clinical and imaging findings, is essential for the early
Conflicts of Interest: The authors have no conflicts of interest to diagnosis of this rare disease.
declare.
Authorship: Both authors contributed to writing this manuscript.
Requests for reprints should be addressed to Toshimasa Yamaguchi,
MD, Primary Care and Advanced Triage Section, Osaka City General Hos-
pital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021,
ACKNOWLEDGMENT
Japan. The authors thank Editage (www.editage.com) for English
E-mail address: dtoryamaguchi@gmail.com language editing.

0002-9343/$ -see front matter © 2021 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
e2
Toshimasa Yamaguchi, MD
Yosuke Yakushiji, MD
Primary Care and Advanced Triage
Section, Osaka City General Hospi-
tal, Japan
https://doi.org/10.1016/j.amjmed.2021.06.039
The American Journal of Medicine, Vol 000, No 000, && 2021
References
1. Hawkes MA, Arena JE, Rollan C, Pujol-Lereis VA, Romero C, Amer-
iso SF. Bilateral paramedian thalamic infarction. Neurologist 2015;20
(5):89–92.
2. Lazzaro NA, Wright B, Castillo M, et al. Artery of percheron infarc-
tion: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol
2010;31(7):1283–9.
3. Bassetti C, Mathis J, Gugger M, et al. Hypersomnia following parame-
dian thalamic stroke: a report of 12 patients. Ann Neurol 1996;
39(4):471–80.