Postgraduate Medical Journal (1989) 65, 316 - 317

Catatonia following biparietal infarction with spontaneous
recovery
Robert J.M.W. Howard and T.S. Low-Beer
Department of Medicine, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK.
Summary:
We describe a case of catatonic stupor following simultaneous biparietal infarction. The
patient recovered, a result not previously described in catatonia caused by this pattern of cerebral infarct.

Introduction
Catatonia is well recognized in association with
organic brain conditions as well as with schizophrenia
and the affective disorders. We report a patient
displaying all the features of catatonia, namely waxy
flexibility, bizarre posturing, stupor, mutism, and
negativism, following spontaneous biparietal infarction. A previous report' has described a patient who,
following biparietal infarction, developed incomplete
features of catatonia which did not recover. Our
patient made a spontaneous recovery from his
catatonic state, suggesting that the prognosis for this
condition following biparietal infarction may be better
than reported.
Case report
A man aged 72 years returned home from a short visit
to the launderette in a state of confusion and agitation.
Perplexed, abusive, and shouting for his wife, who was
present, he was admitted to a psychiatric hospital.
There he refused to answer any questions, but his wife
and general practitioner indicated that he had no past
medical or psychiatric history, was on no medication,
and had sustained no head injury. He was noted to be
in uncontrolled atrial fibrillation, and the blood
pressure was 160/100 mmHg. While he resisted
systematic neurological examination, no abnormality
of limbs, eyes, or cranial nerves was apparent.
He refused all food and drink, and a week later had
developed a right middle lobe pneumonia. Transferred
to a general hospital, he gave a superficial impression
of unconsciousness, but resisted purposefully any
attempt to feed or examine him. A computed tomographic brain scan (Figure 1) showed areas of recent
Correspondence: R.J.M.W. Howard, M.A., M.B., The
Bethlem Royal Hospital, Monks Orchard Road,
Beckenham, Kent BR3 3BX, UK.
Accepted: 30 November 1988

Figure 1 Computed tomography of head showing
bilateral parietal occipital infarction.

infarction in both posterior parieto-occipital regions,
principally in the watershed areas between the middle
and posterior cerebral artery supply areas. Electroencephalography gave only modest non-specific abnormalities, while visual evoked responses showed
intact visual pathways.
The pneumonia responded to intravenous antibiotics within 5 days, and he returned to sinus rhythm,
but remained mute apart from incomprehensible
muttering. He continued to resist feeding, and pulled
out his intravenous and nasogastric tubes. He refused
to open his eyes or mouth when asked, and attempts to
move his arms or legs, or open his eyes and mouth,
were forcibly resisted. Waxy flexibility of his arms was
present. He adopted strange postures, sitting upright
) The Fellowship of Postgraduate Medicine, 1989

CLINICAL REPORTS

in bed holding his arms up like flexed birds' wings.
Over the following 6 weeks he slowly improved to the
point where he would speak rationally to his wife, but
his behaviour was disinhibited. He would grab at the
nurses, refuse to comply with instructions, and showed
wide swings of mood and emotion. At the end of 3
months he was eating and drinking normally, and no
longer showed signs of catatonia. His personality
remained infantile, and neuropsychological assessment revealed amnesic confusion combined with both
expressive and receptive forms of dysphasia. He
returned home to be nursed by his wife.

Discussion

Catatonia has both organic and psychiatric causes. In
a series of 25 cases of catatonia,2 36% were found to
have schizophrenic or affective illness, 20% had a
probable organic cause, and in 40% no organic or
psychiatric cause was found. Cerebrovascular disease
is a well described precipitant: subarachnoid haemorr-

317

hage,3 cortical venous thrombosis,4 thrombotic
thrombocytopenia purpura,S subdural haematoma,6
and cerebral infarction' have been implicated.
Tippin and Dunner described a 45 year old man
with catatonia following biparietal infarction. He was
withdrawn and mute and maintained a bizarre posture, sitting rigidly in a chair leaning towards the right.
This patient showed no 'waxy flexibility'; that is to say
it was not possible to place his limbs and body in
positions which he would then maintain. The
catatonia did not improve despite treatment with
electroconvulsive therapy and haloperidol. Most of
the patients described by Barnes et al.2 either
recovered spontaneously or following electroconvulsive therapy. They found those with an acute and
rapidly progressive course, 'acute lethal catatonia', to
have the worst prognosis, 3 out of 4 dying of acute
renal failure. Persistence of the catatonic state as
described by Tippin and Dunner may, however, be
atypical. The recovery demonstrated by our patient is
more in accord with the result of Barnes' series, and
suggests that the prognosis for recovery from
catatonia following biparietal infarction may be good.

References
1. Tippin, J. & Dunner, F.J. Bi-parietal infarctions in a
patient with catatonia. Am J Psychiatry 1981, 138:
1386-1387.
2. Barnes, M.P., Saunders, M., Walls, T.J., Saunders, I. &
Kirk, C.A. The syndrome of Karl Ludwig Kahlbaum. J
Neurol Neurosurg Psychiatry 1986, 49: 991-996.
3. Thompson, G.N. Cerebral lesions simulating catatonia;
three case reports. Biol Psychiatry 1970, 2: 59-64.

4. Gangadhar, B.N., Keshavan, M.S., Goswani, U. &
Vasuder Rao, T. Cortical venous thrombosis presenting
as catatonia. A clinicopathological report. J Clin
Psychiatry 1983, 44: 109-110.
5. Read, S.L. Catatonia in thrombotic thrombocytopenic
purpura. J Clin Psychol 1984, 44: 343-344.
6. Woods, S.W. Catatonia in a patient with sub-dural
haematomas. Am J Psychiatry 1980, 137: 983-984.