Acute bithalamic infarct manifesting as sleep-like coma: A diagnostic challenge.
Bilateral thalamic infarction (BTI) typically presents as a sleep-like coma (SLC) without localizing signs, posing a diagnostic challenge that may lead the treating physician to search for toxic or metabolic causes and delay treatment. We review our experience with BTI of different etiologies, and emphasize the critical role of timely imaging, diagnosis, and management in a series of 12 patients with a presentation of SLC and acute BTI who were managed in our Medical Centers from 2006-2015. In 11/12, urgent head CT scans showed normal brain tissue, while diffusion-weighted (DWI) MRI revealed symmetric bilateral thalamic hyperintense lesions with variable degrees of brainstem involvement. In 1/12, CT scans revealed a contralateral subacute stroke from a thalamic infarct 1month earlier with a unilateral hyperintense lesion on DWI-MRI. From clinical and imaging findings (DWI-MRI, CT angiography and venography), etiology was attributed to embolic causes (cardio-embolism, artery-to-artery mechanism), small vessel disease, or deep sinus vein thrombosis secondary to dural arteriovenous (AV) fistula. Three patients had good outcomes after prompt diagnosis and optimal treatment in <3hours (intravenous tissue plasminogen activator in two patients cardio-embolic etiology and neuro-endovascular repair in one patient with venous infarction due to a dural AV fistula). The diagnosis was made beyond the therapeutic window in seven patients, who were left with significant neurological sequelae. Higher awareness of BTI presenting as SLC is warranted. Optimal patient management includes urgent DWI-MRI. In cases of BTI, further imaging workup is indicated to provide a comprehensive assessment for etiology. Early diagnosis and prompt, targeted intervention are crucial.
Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. Electronic address: asaf.honig2@gmail.com.
Asaf
A
Honig
Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
Ruth
R
Eliahou
Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
Roni
R
Eichel
Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
Ari Aharon
AA
Shemesh
Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
Tamir
T
Ben-Hur
Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Eitan
E
Auriel
D000368:Aged; D000369:Aged, 80 and over; D001933:Brain Stem / Q000000981:diagnostic imaging; D002544:Cerebral Infarction / Q000150:complications* / Q000000981:diagnostic imaging* / Q000601:surgery; D059345:Cerebral Small Vessel Diseases / Q000150:complications; D003128:Coma / Q000000981:diagnostic imaging* / Q000209:etiology*; D057210:Delayed Diagnosis; D038524:Diffusion Magnetic Resonance Imaging; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000150:complications; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013786:Thalamic Diseases / Q000150:complications* / Q000000981:diagnostic imaging* / Q000601:surgery; D013788:Thalamus / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000150:complications
Bithalamic infarct; Dural arteriovenous fistula; Emergency department; Intravenous thrombolysis; Sleep-like coma