Clinical diagnosis
Case 206
【Progress】
She was given anticoagulants. She was scheduled to take rehabilitation.
【Discussion】
My previous understanding on blood supply to deep central area is as follows: medial lenticulostriate artery and lateral lenticulostriate artery arise from middle cerebral artery and irrigate basal ganglion; thalamus is irrigated from deep posterior cerebral artery; posterior limb of internal capsule, from anterior choroidal artery (1, 2). However, MRI of our case showed the damage of the whole irrigation area of medial and lateral lenticulostriate artery and the occlusive change of anterior cerebral artery.
Internal carotid artery terminally branches to anterior cerebral artery (ACA) and middle cerebral artery (MCA). ACA supplies upper medial upper areas of frontal lobe and parietal lobe, and various central nucleus situated at medial deep area. ACA is categorized into five parts; A1 from internal carotid artery to anterior communicating artery; A2 from anterior communicating artery to branching site between pericallosal artery and calloso-marginal artery branched or to genu of corpus callosum when no branching of calloso-marginal artery exists; A3 pericallosal artery; A4 anterior superior branches of pericallosal artery: A5 posterior branches of pericallosal artery (1).
Medial lenticulostriate artery and lateral lenticulostriate artery are perforating arteries which are thin and directly branched from stem arteries. Medial lenticulostriate artery supplies blood flow to head of caudate nucleus, anterior limb of internal capsule, globus pallidus and medial site of putamen (3, 4). Meanwhile, lateral lenticulostriate artery supplies lateral side of putamen, external capsule and upper internal capsule (corona radiata) (3, 4). In general, medial lenticular striate arteries arise from ACA and/or MCA, and lateral lenticular striate arteries arise from MCA. However, various branching of medial and lateral lenticular striate arteries exists, implying different per person. Then, in case of judging whether it is relates to medial lenticulostriate artery or lateral lenticulostriate artery, it is easier to consider from a point of what parts of nucleus are damaged by ischemia rather than from a point of what stem artery are damaged.
The recurrent artery of Heubner is the largest artery of the medial lenticulostriate arteries. It branches from A2 most (48%) and followed by at the junction of anterior communicating artery (43%) and A3 (5). But other report says it branches from A1 is the most (6-8). Heubner’s artery supplies caudate nucleus head, anterior limb of internal capsule, globus pallidus, and nucleus accumbens. The irrigation area of Heubner’s artery differs per patient. The representative symptoms of ischemia of Heubner’s artery is dysarthria and hemiparesis which met in our case. But hemiparesis occurs following ischemia of either pyramidal tract or extrapyramidal tract.
In our case, brain MRI showed marked left fresh infarction of caudate nucleus head, anterior limb of internal capsule, putamen and upper internal capsule (corona radiata), indicating fresh occlusion of medial lenticular striate artery and a part of lateral lenticulostriate artery. MRA showed the occlusive lesion of A1. It is considered that the occlusive responsible artery is left dominant Hebner’s artery arose from A1, largest artery of medial lenticular striate artery.
Barre sign and Mingazzini sign are used to check whether a patient fell into disorder of mild pyramidal tract and/or extrapyramidal tract of lenticular striate nucleus, or not. Barre sign is as follows: when a patient is lying prone and one’s leg is flexed 90 degree, the patient cannot maintain the lower leg in a vertical position, instead it drops into full extension. Mingazzini test is as follows; when a patient is lying on one’s back and one’s leg is flexed 90 degree, the patient cannot maintain the lower leg in a vertical position, instead it drops into full extension. In our case, Barre sign and Mingazzini sign were positive. Putamen and caudate nucleus make up dorsal striatum. Putamen and globus pallidus make up lentiform nucleus. They function accommodation of movement, as extrapyramidal tract. They connect brain stem, cerebral cortex, thalamus and limbic system. The both tests were positive in our case because of the ischemic damage of extrapyramidal tract.
【Summary】
We present an eighty five-year-old female suffering from right hemiparesis and dysarthria. Both signs of Barre and Mingazzini were positive. Brain MRI showed acute infarction of left caudate nucleus head, putamen, anterior limb of internal capsule and upper internal capsule (corona radiata), indicating irrigation areas of medial lenticulostriate artery and lateral lenticulostriate artery. MRA images depict an occlusive segment of left anterior cerebral artery of A1, probably occlusion of Heubner artery. It is borne in mind that Heubner artery arose from the level of A1, anterior communicating artery, or A2 is a largest branch of medial lenticulostriate artery. The ischemic damage of Hebner artery causes hemiparesis and dysarthria. Medial lenticulostriate artery supplies blood flow to head of caudate nucleus, anterior limb of internal capsule, globus pallidus and medial site of putamen. Meanwhile, lateral lenticulostriate artery supplies lateral side of putamen, external capsule and upper internal capsule (corona radiata).
【References】
1.Gray's anatomy. Churchill Livingstone. (2005) ISBN:0443071683.
2.Dimmick SJ, et al. Normal variants of the cerebral circulation at multidetector CT angiography. Radiographics. 2009;29 (4): 1027-43.
3.Kang HS, et al. Evaluation of the lenticulostriate arteries with rotational angiography and 3D reconstruction. (2005) AJNR. American journal of neuroradiology.2005; 26: 306.
4.DeLong MR; Alexander GE; Georgopoulos AP; Crutcher MD; Mitchell SJ; Richardson RT Role of basal ganglia in limb movements. Human Neurobiology. 1984; 2 (4): 235–44.
5.El Falougy H, et al. The variable origin of the recurrent artery of Heubner: an anatomical and morphometric study. Biomed Res Int. 2013;2013:873434.
6.Lee SH, et al. Bilateral Infarction of the Recurrent Arteries of Heubner Following Clipping of an Anterior Communicating Artery Aneurysm. J Cerebrovasc Endovasc Neurosurg. 2018 Mar;20(1):28-34.
7.Matsuda W, et al. Anatomical variations of the recurrent artery of Heubner: number, origin, and course. Anat Sci Int. 2018 Jun;93(3):317-322.
8.Maga P, et al. Extra- and intracerebral course of the recurrent artery of Heubner. Folia Morphol. (Warsz). 2013 May;72(2):94-9.
2020.9.30