Background  Bilateral paramedian thalamic infarction due to occlusion of the artery of percheron (AOP) is rare in clinical practice, and it is difficult to make early diagnosis. There are few studies on the etiology and the long-term prognosis of this disease.

  Objective  To analyze the clinical manifestations and imaging characteristics of bilateral paramedian thalamic infarction induced by occlusion of AOP, so as to improve the understanding of the disease and diagnosis capabilities.

  Methods  From March 2009 to August 2021, the clinical features, imagines, etiology, treatment and prognosis of 11 cases who were admitted to Southern Theater General Hospital of PLA were analyzed. Among them, there was one case who received intravenous thrombolytic therapy.

  Results  There were 5 male patients and 6 female patients, aged 2-87 years. All the 11 cases had acute onset, 9 cases had sudden disturbance of consciousness, 1 case had seizures and gibberish, and 1 case had memory loss. Reticent and impairment of memory occurred in 7 cases, slight decrease in limb muscle strength in 7 cases, and limited upper and lower movement of eyeball in 5 cases. The brain MRI of 10 patients showed hypointensity T1W1 and hyperintensity T1W2 signals in the median of bilateral thalamus, and the diffusion weighted imaging (DWI) showed hyperintensity. The brain CT of 1 case showed phialiform low density shadow in the paramedian of bilateral thalamus. Eight patients were complicated with partial periaqueductal gray matter infarction in the midbrain, 5 of which were V-shaped infarction. There were 4 cases of cardiogenic embolism, 3 cases of atherosclerosis and 4 cases of unknown cause. All patients were treated with antiplatelet aggregation or anticoagulation, lowering blood lipids, brain protection and improving cerebral circulation, of which 1 case received urokinase thrombolytic therapy, without any sequelae. Of the 9 cases with onset of consciousness disorder, except 1 case died of pulmonary infection, 8 cases had improved clinical symptoms. The clinical symptoms were improved after treatment, and patients were followed up for 3 months to 13 years, with some cases showing memory impairment.

  Conclusion  Bilateral paramedian thalamic infarction due to occlusion of the artery of Percheron starts with typical clinical manifestations such as sudden disturbance of consciousness, cognitive dysfunction and vertical gaze disorder. It is important to make the diagnosis of infarction of percheron artery occlusion based on the clinical manifestation combined with hypointensity on T1WI and hyperintensity on T2WI in bilateral paramedian thalamus as well as hyperintensity on diffusion weighted imaging and the “V” sign in mesencephalen. Early diagnosis and treatment, especially thrombolytic therapy, are essential to improve prognosis.