Artery of Percheron territory infarct

Last revised by Rohit Sharma on 25 Mar 2024

Artery of Percheron territory infarct is rare, on account of the relative rarity of the artery of Percheron, and presents with a variety of signs and symptoms collectively termed the paramedian thalamic syndrome. It is a type of posterior circulation infarction.

On imaging, it is classically characterized by bilateral infarcts in areas involving the rostral midbrain and/or ventromedial thalamus.

Artery of Percheron territory infarcts are thought to account for 4-18% of all thalamic ischemic strokes 2.

The symptoms may vary following infarct extension through thalamic or mesencephalic structures 2:

  • bilateral paramedian thalamic involvement is usually characterized by a triad of

    • altered mental status

    • supranuclear vertical gaze palsy

    • memory impairment

  • when also accompanied by rostral midbrain lesions, a mesencephalothalamic or thalamopeduncular syndrome occurs, which includes other oculomotor disturbances, hemiplegia, cerebellar ataxia, and movement disorders, along with the aforementioned triad

There are four major patterns of artery of Percheron infarction, all of which bilaterally involve the paramedian thalamus 2,9:

  • bilateral paramedian thalamic and midbrain infarction (most common - 35-43%)

  • isolated bilateral paramedian thalamic infarction (35-38%)

  • bilateral paramedian thalamic, anterior thalamic and midbrain infarction (14-26%)

  • bilateral paramedian thalamic and anterior thalamic without midbrain infarction (least common - 5-6%)

Artery of Percheron infarction is best visualized on DWI or FLAIR MRI sequences and it is often missed on initial CT. The midbrain V sign is a feature demonstrated in 30-67% of patients with artery of Percheron infarction involving the midbrain 2,9.

Possible differential considerations include:

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