Abstract

Background: Artery of Percheron (AOP) infarction is a rare ischemic stroke caused by occlusion of a solitary perforating artery supplying both paramedian thalami. It commonly presents with altered consciousness rather than focal neurological deficits, often mimicking metabolic encephalopathy and delaying diagnosis. We report a case of AOP infarction presenting as isolated altered sensorium in a patient with advanced chronic kidney disease (CKD), successfully treated with timely intravenous thrombolysis. Methods: A 70-year-old man with known stage 4 CKD, not on maintenance dialysis, presented with sudden-onset altered sensorium. Neurological examination revealed a low Glasgow Coma Scale score, drowsiness, confusion, impaired attention, and disorientation, while cranial nerve and motor examinations were largely preserved. Despite advanced CKD, the abrupt onset of symptoms and absence of significant metabolic derangements prompted activation of the acute stroke pathway. Magnetic resonance imaging was performed for definitive diagnosis, followed by intravenous thrombolysis within the therapeutic window. Results: MRI demonstrated acute bilateral paramedian thalamic infarction consistent with artery of Percheron occlusion. The patient showed progressive neurological recovery following thrombolysis. During hospitalization, hemodialysis was initiated under nephrology supervision, and he completed multidisciplinary rehabilitation. He was discharged with minimal residual disability, achieving a modified Rankin Scale score of 1. Conclusions: Acute isolated altered sensorium should prompt consideration of artery of Percheron infarction, even in patients with advanced CKD. Early clinical suspicion, prompt neuroimaging, and timely reperfusion therapy can result in excellent functional outcomes despite an initially deceptive presentation.

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