Acute confusional state in a patient with bilateral thalamic ischemic stroke

The acute confusional state is one of the most common reasons for neurologic consultation in the hospital setting and the plethora of causes can truly be daunting. The etiology can vary from structural, metabolic, toxic to systemic infections. Our purpose is to present a rare case of acute confusional state in a patient with bilateral thalamic ischemic stroke due to occlusion of the artery of Percheron (AOP). A 79-year-old woman with a history of hypertension and surgery for lumbar disc herniation, managed on antiplatelet therapy, angiotensin receptor blocker and diuretics, was admitted for acute confusion and paresthesia of all four limbs. She had disorientation in time and space, abnormal behavior, decreased muscle strength in both lower limbs (paraparesis 2/5 MRC since the surgery), paresthesia in all four limbs and was unable to walk due to generalized weakness. Laboratory analysis showed high blood levels of cholesterol and glucose. Both head CT and cerebral MRI showed bilateral ischemic changes in the thalami, suggesting an infarct along the artery of Percheron territory. However, no clear cause for the stroke could be identified. Screening for coagulation abnormalities and autoimmune disorders (lupus anticoagulant, anti-beta-2 glycoprotein, anti-cardiolipin, anti-nuclear and anti-ds DNA antibodies) came back negative. There were no pathological finds on the echocardiogram and electrocardiogram, while cervical Doppler ultrasound showed atherosclerosis without stenosis.