Artery of Percheron Stroke in a Teenager: New Case Report Illuminates Rare Bilateral Thalamic Infarction

Anatomy and Rarity of the Artery of Percheron

The Artery of Percheron represents a vascular variant in which a single arterial trunk arises from one posterior cerebral artery and supplies blood to both paramedian thalami, sometimes extending to portions of the midbrain. This anatomy occurs in roughly one in ten individuals. Occlusion remains exceptionally uncommon, accounting for an estimated 0.1 to 0.3 percent of all ischemic strokes. Because the vessel is not routinely visualized on standard angiography unless specifically sought, many cases go unrecognized until magnetic resonance imaging reveals the characteristic bilateral paramedian thalamic pattern.

Clinicians emphasize that prompt recognition matters because the clinical picture often includes sudden headache, vision disturbance, gait instability, and fluctuating levels of alertness. In pediatric populations the condition is even less frequently encountered, making each documented instance valuable for educational purposes in residency programs and fellowship training.

Clinical Course of the 17-Year-Old Patient

The patient arrived at an outside emergency department with acute encephalopathy after experiencing sudden headache, vision changes, emotional lability, and difficulty walking. Initial head computed tomography was unremarkable. Subsequent magnetic resonance imaging demonstrated bilateral paramedian thalamic infarcts. Digital subtraction angiography confirmed the presence of Artery of Percheron anatomy. An exhaustive etiologic workup, including whole-genome sequencing, thrombophilia panels, and echocardiography with bubble study, yielded no identifiable cause, resulting in a cryptogenic classification.

During hospitalization the teenager reported feeling as though she were “in a dream.” Neuropsychiatric evaluation led to a diagnosis of derealization/depersonalization disorder. Recovery proved gradual at first, with persistent fatigue, inattention, and memory difficulties. On hospital day 29 she experienced a striking spontaneous improvement, describing the sensation that she had “just woke up,” accompanied by sustained gains in attention and memory. This subacute resolution of dissociative symptoms represents a novel observation in the pediatric literature.

Diagnostic and Therapeutic Considerations

Standard stroke protocols in adolescents require adaptation because common adult risk factors such as atherosclerosis are rare. Magnetic resonance imaging remains the cornerstone for identifying bilateral thalamic involvement, while vascular imaging helps delineate the Artery of Percheron variant. Differential considerations include cerebral venous sinus thrombosis and other rare vasculopathies, all of which must be systematically excluded.

Management in this instance centered on supportive care, rehabilitation, and monitoring for complications. No specific reperfusion therapy was administered once the window for intravenous thrombolysis had passed. The case illustrates how supportive neurorehabilitation can facilitate meaningful functional gains even when the precise mechanism remains elusive.

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Implications for Pediatric Neurology Training and Research

Case reports of this nature serve as important teaching tools within academic medical centers. Trainees learn to maintain a high index of suspicion for atypical stroke presentations in young patients and to appreciate the thalamus’s contribution to higher-order functions beyond motor and sensory pathways. Faculty members at institutions such as the University of Utah, where several of the authors hold appointments, integrate such material into didactic sessions and grand rounds.

The publication also highlights opportunities for collaborative research between pediatric neurology, neurosurgery, and neuroradiology departments. Multi-institutional registries of rare cerebrovascular events in children could accelerate understanding of natural history and optimal management strategies.

Broader Context of Rare Stroke Syndromes in Adolescents

While ischemic stroke incidence in children and adolescents is substantially lower than in older adults, the consequences can be life-altering. Cryptogenic cases predominate in the young, prompting ongoing investigation into genetic, inflammatory, and prothrombotic contributors. Educational curricula in neurology and pediatrics increasingly incorporate modules on posterior circulation variants and thalamic syndromes to prepare future clinicians.

Academic medical centers play a central role in advancing this field through fellowship programs that emphasize both clinical care and scholarly output. Publications like the present one provide concrete examples that enrich classroom discussions and bedside teaching.

Recovery Patterns and Long-Term Outlook

The dramatic improvement observed on hospital day 29 suggests that some thalamic circuits may enter a temporarily stunned state rather than permanent damage. Longitudinal follow-up will be essential to determine whether residual cognitive or psychiatric symptoms persist. Such observations encourage clinicians to counsel families about the potential for delayed but meaningful recovery.

Rehabilitation teams focusing on cognitive remediation, psychological support for dissociative symptoms, and gradual return to academic activities can optimize outcomes. Universities and teaching hospitals are well positioned to study these recovery trajectories through dedicated neurorehabilitation research programs.

Contribution to Academic Medicine and Future Directions

This case adds to a small but growing literature on Artery of Percheron infarction in the pediatric age group. It is believed to be the first reported instance in which derealization/depersonalization disorder formed a prominent part of the clinical picture. The authors’ affiliation with a major academic medical center underscores the value of protected time for clinician-scientists to document and analyze unusual presentations.

Future research may explore advanced imaging techniques, biomarkers of thalamic recovery, and targeted cognitive interventions. Funding agencies and academic departments that support such inquiry help ensure that rare conditions receive appropriate attention within the broader stroke research portfolio.

Readers interested in the full details may consult the original publication directly: https://www.sciencedirect.com/science/article/abs/pii/S0887899426001827. Additional context on Artery of Percheron territory infarcts is available from established neuroradiology resources such as Radiopaedia.

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Relevance to Medical Education and Career Pathways

Exposure to rare case material during training cultivates diagnostic humility and intellectual curiosity—qualities highly valued in academic neurology. Medical students and residents considering subspecialty careers in pediatric neurology or stroke can draw inspiration from the collaborative authorship model demonstrated here, which spans multiple disciplines.

Academic job markets continue to seek faculty members who combine clinical excellence with scholarly productivity. Institutions benefit when early-career clinicians contribute to the literature in this manner, strengthening both departmental reputations and the educational experience offered to the next generation of physicians.