Eur Neurol 2001;45:122–123 Apraxia of Eyelid Closure Complicating Right Parietal Infarction Tadanori Hamano, Seigo Kimura, Shin’ichi Miyao, Jun Teramoto Department of Neurology, Meitetsu Hospital, Nagoya, Japan Apraxia of eyelid closure is an uncommon condition characterized by difficulties in voluntary eye closing with normal blinking, or closing eyes in response to a perceived threat [1]. We report here a case of apraxia of eyelid closure complicating right parietal infarction. An 81-year-old right-handed male was hospitalized for rehabilitation of moderate left hemiparesis due to cerebral infarction. He had a past history of gastric ulcer, and hypertension at age 68. On admission, his consciousness level was alert. He showed moderate dementia, 11/30 on the Hasegawa-Dementia Score-Revised. He was normally orientated in time, place, and persons, and did not exhibit aphasia. However, he could not respond to requests to close his eyes voluntarily. Rarely, he could comply with the request to close the eyelids, however, once he could close eyelids, he could not voluntarily keep the eyelids closed for more than a few seconds. Reflex blinking in response to a visual or auditory threat or corneal stimulation was normal. Spontaneous blinking was also observed during conversation. It was also observed that the eyes closed normally in sleep. Opening of the eyelids presented no difficulties. The patient also showed constructional apraxia, and geographical agnosia. There was no dressing or ideomotor apraxia, and no left-right disorientation observed. Upward gaze was mildly restricted. Myerson’s sign was positive. Bilateral corneal reflex was normal. He showed no facial muscle weakness or atrophy. He could protrude the tongue immediately when requested. Mild weakness of the left upper and lower limb was found. Deep tendon reflexes were slightly increased in the lower extremities. There were no pathological reflexes. Hypertonia was observed in four limbs. Sensory and cerebellar functions were normal. Routine laboratory examinations showed mild anemia as 122 Short Reports including postcentral gyrus. This patient also exhibited constructional apraxia, and topographical amnesia. These symptoms could be caused by right parietal lobe lesion. Aramideh et al. [7] reported a similar case presenting with inability to voluntarily close the eyelids but with preservation of spontaneous blinking and denial of eye opening following unilateral parietal lobe infarct including the postcentral gyrus recognized by CT. To our knowledge, this is the first report of apraxia of eyelid closure following cerebral infarction, in which the responsible lesion was clearly demonstrated by MRI. We should recognize that right parietal lesion may be responsible for apraxia of eyelid closure. References Fig. 1. T1- (a) and proton density-weighted (b) MRI findings of the brain (1.0 tesla). Infarction of the right parietal lobe, corresponding to the watershed area between the left middle and posterior cerebral artery, was shown. Massive leukoaraiosis and moderate bilateral frontal atrophy were also noted. follows: red blood cells and hemoglobin were 353 ! 104/mm3 and 10.6 g/dl, respectively. On T1- and proton density-weighted magnetic resonance imaging (MRI), a large, wedge-shaped infarction was noted in the right parietal lobe, in the vascular area of the posterior branch of the right middle cerebral artery. The lesion affected the lower two thirds of the parietal lobe and affected the anterior lower half of the postcentral gyrus. Severe leukoaraiosis, atrophy of the bilateral frontal lobe and enlargement of the lateral ventricle were also noted (fig. 1). Disturbances of voluntary eyelid closure have been divided into two categories: apraxia of eyelid closure [1] and motor impersistence (MI) [2]. The pathophysiology of these conditions remains to be fully elucidated. Commonly, differences between the two symptoms are explained as follows. In apraxia of eyelid closure, if a patient is requested to close his eyes, he shows difficulty in initiation of eyelid closing, while in case of MI, if a patient is requested to close his eyes, he would be able to close them but almost immediately reopen them [2]. This patient had difficulty in voluntary eyelid closure with normal reflex blinking in response to a visual or auditory threat or corneal stimulation. So, it was reasonable to consider that this patient had apraxia of eyelid closure. Quite rarely, he could comply with the request to close the eyelids, however, once he closed the eyelids, he could not keep them closed. Therefore, his symptom also suggested MI. Apraxia of eyelid closure has been reported earlier in patients with parkinsonism, Creutzfeldt-Jakob disease [3], motor neuron disease, including amyotrophic lateral sclerosis [4, 5] and primary lateral sclerosis [6], progressive supranuclear palsy, cerebral infarction [5, 7–9], and cortical angioma [10]. The cases presenting apraxia of eyelid closure are divided into two types, with or without corticobulbar signs. Corticobulbar signs are detected in the majority of patients [3–6, 10]. The lesions corresponding to apraxia of eyelid closure are still unclear, although it is currently assumed that lesions at the following sites are responsible: (1) bilateral frontal lobe [4, 5], (2) bilateral motor cortices [6], (3) right parietal cortex [1, 7, 9, 10], and (4) bilateral rolandic operculum. Our case showed right parietal lobe infarct Short Reports 1 Lewandowsky M: Über Apraxie des Lidschlusses. Berl Klin Wochenschr 1907;44:921–923. 2 Fisher M: Left hemiplegia and motor impersistence. J Nerv Ment Dis 1956;123:201–218. 3 Russell RW: Supranuclear palsy of eyelid closure. Brain 1980;103:71–82. 4 Abe K, Fujimura H, Tatsumi C, Toyooka K, Yorifuji S, Yanagihara T: Eyelid ‘apraxia’ in patients with motor neuron disease. J Neurol Neurosurg Psychiatry 1995;59:629–632. 5 Lessell S: Supranuclear paralysis of voluntary lid closure. Arch Ophthal 1972;88:241–244. 6 Nishimura M, Tojima M, Suga M, Hirose K, Tanabe H: Chronic progressive spinobulbar spasticity with disturbance of voluntary eyelid closure. Report of a case with special reference to MRI and electrophysiological findings. J Neurol Sci 1990;96:183–190. 7 Aramideh M, Kwa IH, Brans JWM, Speelman JD, Verbeeten B Jr: Apraxia of eyelid closure accompanied by denial of eye opening. Mov Disord 1997; 12:1105–1108. 8 Rosati G, De Bastiani P, Granieri E, Agnetti V: Voluntary lid closing inability: Release of a compulsive reaction to the exploration of the environment. Arch Psychiatr Nervenkr 1978;226:11–17. 9 Colombo A, De Renzi E, Gibertoni M: Eyelid movement disorders following unilateral hemispheric stroke. Ital J Neurol Sci 1982;3:25–30. 10 Monaco F, Pirisi A, Sechi GP, Cossu G: Acquired ocular-motor apraxia and right-sided cortical angioma. Cortex 1980;16:159–167. Tadanori Hamano, MD Second Department of Internal Medicine, Fukui Medical University 23-3 Shimoaizuki, Matsuoka-cho, Yoshida-gun, Fukui, 910-1193 (Japan) Tel. +81 776 61 3111, ext. 2300, Fax +81 776 61 8110 E-Mail hamano@fmsrsa.fukui-med.ac.jp 123 Copyright: S. Karger AG, Basel 2001. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.