Successful Outcome in an Adolescent with Artery of Percheron Occlusion who was Treated with Tissue Plasminogen Activator



      Ischemic stroke is relatively rare in children, leading to a low level of suspicion and delayed diagnosis, particularly in cases of posterior circulation occlusion when symptoms are less indicative. Occlusion of the artery of Percheron (AOP) results in nonspecific neurologic symptoms, including drowsiness, aphasia or dysarthria, ophthalmoplegia, ataxia, and dysmetria. Previous reports, mainly in adults, described late diagnosis and severe residual disability.

      Case Report

      We report a case of a 16-year-old male who presented to the pediatric emergency department with altered mental status. There was no history of trauma or intoxication. The main symptoms included confusion, slurred speech, and multiple falls starting 1 h before arrival to the emergency department. No motor deficits or other focal signs were noticed. The patient's consciousness gradually decreased followed by apneic events. Routine laboratory tests, urinary toxic screen, and a computed tomography scan of the head were normal. A magnetic resonance imaging scan of the brain revealed bilateral restrictive changes in the thalamus. A diagnosis of AOP occlusion was made, and the patient was treated with tissue plasminogen activator (6 h after symptom onset). He was extubated on day 4 and discharged on the day 10 of admission without any neuropsychological deficit.

      Why Should an Emergency Physician Be Aware of This?

      Posterior circulation stroke in the pediatric population is a diagnostic challenge that often results in suboptimal treatment and unfavorable outcomes. Prompt imaging studies in children with nonspecific altered mental status enable timely diagnosis and thrombolytic treatment that may substantially improve the outcome.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Merwick Á
        • Werring D.
        Posterior circulation ischaemic stroke.
        BMJ. 2014; 348: g3175
        • Harrar DB
        • Salussolia CL
        • Kapur K
        • et al.
        A stroke alert protocol decreases the time to diagnosis of brain attack symptoms in a pediatric emergency department.
        J Pediatr. 2020; 216 (e6): 136-141
        • Kichloo A
        • Jamal SM
        • Zain EA
        • Wani F
        • Vipparala N.
        Artery of Percheron infarction: a short review.
        J Investig Med High Impact Case Rep. 2019; 72324709619867355
        • Amin OSM
        • Shwani SS
        • Zangana HM
        • Hussein EM
        • Ameen NA.
        Bilateral infarction of paramedian thalami: a report of two cases of artery of Percheron occlusion and review of the literature.
        BMJ Case Rep. 2011; (bcr.09.2010.3304): 2011
        • Matheus MG
        • Castillo M.
        Imaging of acute bilateral paramedian thalamic and mesencephalic infarcts.
        AJNR Am J Neuroradiol. 2003; 24: 2005-2008
        • Saida IB
        • Saad HB
        • Zghidi M
        • Ennouri E
        • Ettoumi R
        • Boussarsar M.
        Artery of Percheron stroke as an unusual cause of hypersomnia: a case series and a short literature review.
        Am J Mens Health. 2020; 141557988320938946
        • Ranasinghe K
        • Herath H
        • Dissanayake D
        • Seneviratne M.
        Artery of Percheron infarction presenting as nuclear third nerve palsy and transient loss of consciousness: a case report.
        BMC Neurol. 2020; 20: 320
        • Pitts-Tucker T
        • Small J.
        Artery of Percheron: an unusual stroke presentation.
        BMJ Case Rep. 2018; 2018 (bcr-2017-222185)
        • Agarwal S
        • Chancellor B
        • Howard J.
        Clinical-radiographic correlates of artery of Percheron infarcts in a case series of 6 patients.
        J Clin Neurosci. 2019; 61: 266-268
        • Folsom AR
        • Rosamond WD
        • Shahar E
        • et al.
        Prospective study of markers of hemostatic function with risk of ischemic stroke. The Atherosclerosis Risk in Communities (ARIC) Study Investigators.
        Circulation. 1999; 100: 736-742
        • Amlie-Lefond C
        • Shaw DWW
        • Cooper A
        • et al.
        Risk of intracranial hemorrhage following intravenous tPA (tissue-type plasminogen activator) for acute stroke is low in children.
        Stroke. 2020; 51: 542-548