VISUAL VIGNETTE Limb-Kinetic Apraxia Due to Injury of the Corticofugal Tract from the Secondary Motor Area in a Stroke Patient Sung Ho Jang, MD, Chul Hoon Chang, MD, and Han Do Lee, MS From the Departments of Physical Medicine and Rehabilitation (SHJ, HDL) and Neurosurgery (CHC), College of Medicine, Yeungnam University, Taegu, Republic of Korea. This work was supported by the National Research Foundation (NRF) of Korea Grant funded by the Korean Government (MSIP) (2015R1A2A2A01004073). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/16/0000-0000 American Journal of Physical Medicine & Rehabilitation Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000474 A 52-year-old right-handed male patient presented with complete weakness of the left extremities at the onset of hemorrhagic transformation after right middle cerebral artery territory infarct. When he started rehabilitation at 2 weeks after onset, he exhibited severe left hemiparesis with complete weakness of the left finger flexor and extensor (manual muscle test result, 0/0). The patient_s scores on the Mini-Mental State Examination and the ideomotor apraxia test were 28 (cutoff score, G25) and 40 (cutoff score, G32), respectively. The patient underwent a comprehensive rehabilitative management program, including movement therapy and neurotrophic drugs (ropinirole, 3 mg; amantadine, 300 mg; and levodopa, 500 mg).1,2 During a 2-week period of intensive rehabilitation, the patient showed significant motor recovery in the left extremities to the extent of a nearly normal state including finger flexor and extensor (manual muscle test result: 4+/4+). A 6-channel head coil on a 1.5-T Philips Gyroscan Intera was used for acquisition of diffusion tensor imaging data at 2 weeks after onset. For reconstruction of the corticospinal tract (CST), the upper pons and mid pons on the color map. For reconstruction of the corticofugal tracts (CFTs) from the premotor cortex (PMC) and supplementary motor area (SMA). The integrities of the CST, the CFT from the PMC, and the CFT from the SMA were preserved in both hemispheres (Fig. 1). However, the CST, the CFT from the PMC, and the CFT from the SMA were thinner than those of the left side, respectively. We think that the motor weakness of the left extremities observed in this patient was mainly ascribed to FIGURE 1 A. T2-weighted magnetic resonance images of the brain show a hemorrhagic lesion located in the right hemisphere. B. Diffusion tensor tractography for the CST and CFT from the PMC and SMA. The integrities of the CST, the CFT from the PMC, and the CFT from the SMA are preserved in both hemispheres. However, the CST, the CFT from the PMC, and the CFT from the SMA are thinner than those of the left side, respectively. All correspondence and requests for reprints should be addressed to: Han Do Lee, MS, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, 317-1, Daemyungdong, Namku, Taegu, 705-717, Republic of Korea. www.ajpmr.com Visual Vignette Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 1 limb-kinetic apraxia (LKA) as well as the injury of the CST for the following reasons. We confirmed the partial injury of the right CST and CFTs from the secondary motor area, which are responsible for LKA.3 The patient showed rapid motor recovery for 2 weeks to a nearly normal state with rehabilitation including dopaminergic drugs, which are known to be effective for LKA.1,2 As a result, we assume that the motor recovery was mainly attributed to improvement of LKA as well as the recovery of the injured CST and resolution of local factors such as perihematomal edema.1,2 Limb-kinetic apraxia is defined as a disorder of execution of movement, resulting from injury of the secondary motor area or the CFT from the secondary motor area.4 Our results suggest that diffusion tensor tractography for the CFT from the secondary motor area could be helpful for diagnosis of LKA.2 2 Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016 Visual Vignette REFERENCES 1. Yamada S, Matsuo K, Hirayama M, et al: The effects of levodopa on apraxia of lid opening: a case report. Neurology 2004;62:830Y1 2. Jang SH: Motor recovery by improvement of limb-kinetic apraxia in a chronic stroke patient. NeuroRehabilitation 2013;33:195Y200 3. Newton JM, Ward NS, Parker GJ, et al: Non-invasive mapping of corticofugal fibres from multiple motor areasVrelevance to stroke recovery. Brain 2006;129:1844Y58 4. Leiguarda RC, Marsden CD: Limb apraxias: higher-order disorders of sensorimotor integration. Brain 2000;123(Pt 5):860Y79 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.