What is the management of an occluded Artery of Percheron?

Management of Artery of Percheron Occlusion

Acute Management

Artery of Percheron occlusion should be managed as an acute ischemic stroke with immediate transfer to a stroke center for consideration of thrombolytic therapy within 4.5 hours of symptom onset. 1

Immediate Actions

• Transfer immediately to a stroke center (or emergency department if stroke center unavailable) as this represents an acute ischemic stroke requiring emergent evaluation 1
• Consider intravenous thrombolysis if presenting within 4.5 hours of symptom onset, as patient-level meta-analyses show 50% clinical recovery rates when treated within this window 1
• Both intra-arterial and intravenous thrombolytic approaches have been investigated for posterior circulation strokes, though optimal strategy remains debated 1

Diagnostic Considerations

• Early imaging (CT or MRI) may be falsely negative in the acute phase of Artery of Percheron infarction 2, 3
• The diagnosis can be missed initially because bilateral paramedian thalamic infarcts may not appear on imaging for 24-48 hours after symptom onset 2, 3
• If clinical suspicion is high (altered consciousness, hypersomnia, vertical gaze palsy, memory impairment), repeat imaging in 24-48 hours even if initial studies are normal 2, 3
• Brain angiography can confirm the vascular variant and occlusion 4

Long-Term Secondary Prevention

Antiplatelet and Statin Therapy

• Initiate antiplatelet therapy (aspirin 325 mg daily or clopidogrel 75 mg daily) for secondary stroke prevention 1
• Start statin therapy as indicated for the majority of ischemic stroke patients 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) carries increased bleeding risk and should be reserved for specific high-risk scenarios 5

Workup for Stroke Mechanism

• Evaluate for cardioembolic sources including patent foramen ovale, which has been reported as a cause of Artery of Percheron occlusion 6
• Assess for carotid stenosis and other large vessel disease 1
• Screen for hypercoagulable states in younger patients or those without traditional vascular risk factors 6

Risk Factor Management

• Control hypertension, hypercholesterolemia, and diabetes as these are modifiable stroke risk factors 1
• Address lifestyle factors including alcohol consumption, which may contribute to stroke risk 3

Clinical Pitfalls

• Do not rely on normal initial imaging to exclude the diagnosis - Artery of Percheron infarcts frequently show delayed radiological findings despite acute symptoms 2, 3
• The clinical presentation is highly variable due to complex thalamic anatomy, making diagnosis challenging 2, 7
• This variant accounts for only 0.1-2% of all ischemic strokes but represents 4-35% of thalamic strokes specifically 3
• Confusion with other conditions (tumors, infections, metabolic encephalopathy) can delay appropriate stroke treatment 3