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The artery of Percheron is an uncommon variant in thalamic vasculature in which a single artery supplies bilateral medial thalami and rostral midbrain. Presentation of infarcts in this territory can vary widely and range from mild confusion to coma, reflecting differing degrees of damage to thalamic intralaminar nuclei involved in the ascending reticular activating system and alert consciousness. Early identification and time-sensitive intervention in these rare infarcts can result in dramatic and longstanding clinical improvements.

A comprehensive chart review as well as literature review was performed.

A previously healthy 45 year old right-handed female developed acute onset somnolence, right-sided weakness, and aphasia at work. Upon arrival to the emergency room 45 minutes after her last known normal, her NIHSS (National Institutes of Health Stroke Scale) was 19. CT head obtained without acute findings, CTA without large vessel occlusion, and no contraindications to thrombolytic therapy so IV tPA (tissue plasminogen activator) was given 75 minutes after last known normal. 15 minutes after tPA given patient had acute worsening in her neurological exam with obtundation, miotic pupils, disconjugate gaze, and right arm and leg posturing. While en route for STAT repeat CT had sudden resolution of all prior symptoms with NIHSS of 0 upon reevaluation. Some mild subjective diplopia and lateral deviation of right pupil on upgaze noted but otherwise no neurological deficits. MRI brain showed evolving acute infarcts of bilateral paramedian thalami compatible with artery of Percheron infarct. Extensive cardioembolic and hypercoagulability workup performed and negative, disclosed history of cocaine use earlier that month. She did not have any therapy needs, was discharged on antiplatelet therapy and continues to do well.

Artery of Percheron territory syndrome is a rare form of ischemic stroke in which early recognition and appropriate time-sensitive interventions can have significant positive effects on patient outcomes.