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Heart appearance sign in pontine stroke: A result of bilateral infarction due to small vessel disease Prasanna Venkatesan, R. Balakrishnan, K. Ramadoss, Rajesh Shankar Iyer1 Departments of Neurology, PSG Institute of Medical Sciences and Research, 1KG Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu, India We describe an interesting appearance of pontine infarction in the shape of heart and discuss the cause. A 53-year-old diabetic and hypertensive suddenly developed vertigo and slurring of speech. He was drowsy and unresponsive to pain. Doll’s eye reflex was absent and plantar was bilaterally extensor. Magnetic resonance imaging of brain revealed bilateral pontine infarction with the characteristic “heart appearance” on axial images [Figure 1a-c]. Magnetic resonance-angiography showed features of atherosclerotic vertebral and basilar artery disease [Figure 1d]. He remained tetraplegic despite good supportive care. The heart appearance sign is well-described in bilateral medial medullary infarction. [1] Only one report is available describing such an appearance in pontine infarction.[2] In a review of 150 cases of pontine infarction, Kumral et al. reported 14 cases (11%) of bilateral pontine infarction.[3] Seven of them represented schematically in their paper had the heart appearance though they never mentioned this. The blood supply of pons and the heart appearance is depicted schematically in Figure 2. Pons is supplied by the basilar artery through its three branches. The paramedian arteries supply the antero-medial arterial territory while the short circumferential branches supply the antero-lateral pons. The long circumferential branches namely anterior inferior cerebellar artery and superior cerebellar artery

a

b

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d

Figure 1: Magnetic resonance imaging brain images showing acute pontine infarction with the characteristic “heart appearance” seen on diffusionweighted image (a) and T2-weighted images (c). Corresponding apparent diffusion coefficient map shows restricted diffusion in the same territories (b). Magnetic resonance angiography at the time of infarct shows diffuse atherosclerotic disease of the vertebral and basilar arteries (d)

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Figure 2: Schematic diagram showing the three arterial territories of pons and the heart appearance arising out of involvement of the anteromedial and antero-lateral arterial territories. CST - Corticospinal tract, ML - Medial leminiscus, SON - Superior olivary nucleus, MLF - Medial longitudinal fasciculus

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supply the lateral territory. For the heart appearance to occur, there should be bilateral involvement of the antero-medial and the antero-lateral arterial territories sparing the lateral territories. This may happen with atherothrombotic disease of the basilar artery selectively involving the bilateral paramedian and short circumferential branches and sparing the long circumferential branches. Address for correspondence: Dr. Rajesh Shankar Iyer, Department of Neurology, KG Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu, India. E-mail: [email protected]

References 1. 2. 3.

Krishnan M, Rajan P, Kesavadas C, Iyer RS. The ‘heart appearance’ sign in MRI in bilateral medial medullary infarction. Postgrad Med J 2011;87:156-7. Ishizawa K, Ninomiya M, Nakazato Y, Yamamoto T, Araki N. “Heart appearance” infarction of the pons: A case report. Case Rep Radiol 2012;2012:690903. Kumral E, Bayülkem G, Evyapan D. Clinical spectrum of pontine infarction. Clinical-MRI correlations. J Neurol 2002;249:1659-70.

How to cite this article: Venkatesan P, Balakrishnan R, Ramadoss K, Iyer RS. Heart appearance sign in pontine stroke: A result of bilateral infarction due to small vessel disease. Neurol India 2014;62:115-6. Source of Support: Nil, Conflict of Interest: None declared.

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