A very high PIM prevalence at discharge was reported suggesting the urgent need for actions to reduce them. STOPP version 2 criteria identified significantly more PIMs than the EU(7)-PIM list and the comprehensive protocol and was found as a more sensitive tool for PIM detection.

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A 32-year-old white woman presented with acute onset of right limb weakness, 3 days before hospitalization. She had non-regulated hyperthyreoidism and a history of smoking. Brain computed tomography (CT) showed a several occipital and high parietal ischemic lesions of the left hemisphere [ Figure 1a and b]. Duplex ultrasonography scan (DUS) showed the existence of fibrolipid plaque located on the back wall of the common carotid artery, that extended to the external as well as internal carotid artery making an uneven plaque, a part of which moved up and down with the heart beat, creating stenosis of 80-90% [ Figure 1c and d]. CT angiography revealed unstable plaque in left internal carotid artery that protrudes into the lumen as well as moderate stenosis in the proximal segment of the external carotid artery [ Figure 2]. She underwent total carotid endarterecotomy of symptomatic left internal carotid artery, 25 days after being admitted. Histopathological finding indicated that the plaque was atherosclerotic. In the prevention of stroke recurrence, the patient was given 75 mg of clopidogrel and 100 mg of aspirin daily. The patient did well, with residual discrete right-sided weakness and no recurrent strokes. Follow-up DUS was done and it showed no signs of plaque or restenosis.Mobile carotid plaques are unstable and associated with recurrent stroke, [1] with the estimated prevalence of 1 in 2000. [2] They bear high risk of embolic cerebrovascular incidents, as was the case in our patient. This type of plaque usually represents degenerated atherosclerotic flap, ruptured plaque with mobile thrombus or intimal dissection plaque. The only method that can show the mobility of the plaque is ultrasonography. [1] Mobile floating carotid plaques can be treated with urgent carotid endarterectomy, delayed carotid endarterectomy and carotid angioplasty and stenting. [2,3] Beside surgery, patients are treated with antiplatelet therapy. [2] Neuroimage Figure 1: Brain computed tomography showed several occipital and high parietal ischaemic leasions of the left hemisphere (a, b). Duplex ultrasonography scan revealed fibrolipid plaque located on the back wall of the common carotid artery, that extended to the external as well as internal carotid artery making an uneven plaque (c, d) d c b a Figure 2: Computed tomographic angiography of the neck showed unstable plaque in left internal carotid artery that protrudes into the lumen as well as moderate stenosis in the proximal segment of external carotid artery. Axial source imaging (a, b) and 3D reconstruction imaging (c, d) d c b a

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Sažetak:Uvod: Bilateralni talamički infarkti su retki i obično udruženi sa tipičnom kliničkom slikom koja, pored ostalog, uključuje i neuropsihološke promene. Prikaz slučaja: Prikazan je slučaj tridesetsedmogodišnje žene sa akutno nastalim diplopijama usled "skew" devijacije, centralnom desnostranom parezom mimične muskulature, levostranom hemihipestezijom, ataksijom, sa očuvanim nivoom svesti i bez ikakvih neuropsiholoških smetnji, izuzev blagog memorijskog deficita. Postavljena je dijagnoza bilateralnog talamičkog infarkta uzrokovanog kardioembolizacijom preko perzistentnog foramena ovale. Zaključak: U slučajevima bilateralnog talamičnog infarkta može se pretpostaviti postojanje retke anatomske varijante talamičke perfuzije poznate kao Percheronova arterija, jedinstvenog stabla koje se grana za irigaciju oba paramedijalne talamičke zone. Uzrok infarkta može biti kardioembolizacija kroz perzistentni foramen ovale, naročito kod mladih ljudi. Naš slučaj prikazuje kombinaciju dva specifična patološka stanja -perzistentnog foramena ovale i bilateralnog talamičkog infarkta. Klinička prezentacija u ovom slučaju je atipična za bilateralni paramedijalni infarkt. Ključne reči: bilateralni talamički infarkt, "skew" devijacija, perzistentni foramen ovale, Percheronova arterija. Summary:Background: Simultaneous bilateral thalamic infarctions are rare and in most cases associated with typical clinical pattern which, beside other things, include neuropsychological changes. Case report: We report a case of a 37-year-old woman with acute onset ofdiplopia from skew deviation, right-sided central facial nerve palsy, left hemihypesthesia, ataxia, with normal level of consciousness and without any neuropsychological disturbances except minor memory deficit. She was diagnosed with bilateral thalamic infarction due to the cardioembolisation via patent foramen ovale. Conclusion: In cases of bilateral thalamic infarction one can presume the existence of rare anatomic variant of thalamic perfusion commonly known as the artery of Percheron, single artery trunk that branches to irrigate both paramedian territories of thalamus. The cause of infarction can be cardioembolism trough the patent foramen ovale, especially in young adults. Our case represents a combination of two specific pathological conditions -patent foramen ovale and bilateral thalamic infarction. Clinical presentation in this case was unusual for the bithalamic paramedian infarction.