Simultaneous Bithalamic Infarctions: Diagnostic Challenges in Low-Resource Settings —A Six-Case Series

Abstract

Introduction : Simultaneous bithalamic infarction is rare and is typically related to occlusion of a common trunk supplying both paramedian thalamic arteries, known as the artery of Percheron. However, a few cases of bithalamic infarction secondary to deep cerebral venous thrombosis have been reported. The clinical picture is heterogeneous, non-specific, and often misleading. Methods : We conducted a descriptive study of six consecutive patients hospitalised for management of bithalamic infarction between 23 April 2017 and 1 November 2024 in the neurology departments of Libreville University Hospital and Lomé University Hospital. Results : The mean age was 58 years with a female predominance (sex ratio M:F = 1:5). Clinical presentation was polymorphic, most commonly with impaired consciousness, followed by motor, oculomotor, and finally cognitive disturbances. Bilateral thalamic involvement was demonstrated in all patients on brain CT. One out of two patients underwent brain MR angiography or CT angiography. An artery of Percheron occlusion was diagnosed in four patients, and deep cerebral venous thrombosis in two. Most patients received anticoagulation with low-molecular-weight heparin followed by vitamin K antagonists. Overall outcomes were unfavourable: two deaths, one patient lost to follow-up, and moderate to severe sequelae in the remaining three. Conclusion : Because of its varied and non-specific presentation and the diversity of causes of bilateral thalamic lesions, bithalamic infarction poses genuine diagnostic challenges. These challenges are compounded in our setting, where access to brain and supra-aortic trunk MR angiography remains limited.