Emond H, Landis T, Perren F
J Neurol. 2009 Jun;256(6):1007-8. doi: 10.1007/s00415-009-5030-9. Epub 2009 Mar 1.
Bilateral paramedian thalamic infarctions are usually associated with impaired consciousness, oculomotor disturbances and neuropsychological changes. A 44-year-old healthy woman presented with amaurosis fugax of the right eye immediately after a Valsalva maneuver. Neurological examination, in particular visual acuity, vigilance and ocular movements, was normal. Blood pressure, ECG and angio-CT of the neck and head vessels were normal, but MRI/DWI and T2 sequences showed recent bi-thalamic ischemic lesions in the paramedian territories. Doppler sonography and transesophageal echocardiography showed a large right-to-left shunt due to an atrial communication, with septum aneurysm. Twenty-four-hours cardiac monitoring was normal but prior to an eventual closure of the cardiac defect she underwent an ambulatory 7-day ECG monitoring which revealed several paroxystic short lasting passages into atrial fibrillation, unnoticed by the patient. The interest in this case is threefold: (1) bilateral paramedian thalamic infarction which usually presents with a devastating clinical picture may occur clinically silent; (2) monocular amaurosis fugax which is usually associated with ipsilateral carotid disease may be the consequence of cardiac embolism, and (3) atrial fibrillation is never completely ruled out, here it was caught only in a 7-days ambulatory R-test, and consequently prevented closure of a possibly asymptomatic patent foramen ovale.
双侧丘脑旁正中梗死通常与意识障碍、动眼神经功能障碍及神经心理改变相关。一名44岁健康女性在进行瓦尔萨尔瓦动作后立即出现右眼一过性黑矇。神经系统检查，尤其是视力、警觉性和眼球运动均正常。血压、心电图以及颈部和头部血管的血管造影CT均正常，但MRI/DWI及T2序列显示丘脑旁正中区域近期有双侧缺血性病变。多普勒超声和经食管超声心动图显示由于心房交通伴房间隔瘤形成导致大量右向左分流。24小时心脏监测正常，但在最终关闭心脏缺损之前，她接受了为期7天的动态心电图监测，结果显示有几次短暂发作的阵发性房颤，患者未察觉。该病例的意义有三点：（1）双侧丘脑旁正中梗死通常表现为严重的临床症状，但也可能临床无症状；（2）通常与同侧颈动脉疾病相关的单眼一过性黑矇可能是心脏栓塞的结果；（3）房颤永远不能完全排除，在此病例中仅通过7天的动态心电图检查发现，从而避免了可能无症状的卵圆孔未闭的封堵。
