YAJEM-56265; No of Pages 2
American Journal of Emergency Medicine xxx (2016) xxx–xxx

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American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem

Akinetic mutism revealing an ischemic stroke
Saad Zidouh ⁎, Said Jidane, Ahmed Belkouch, Hicham Bakkali, Lahcen Belyamani
Emergency Department Military Hospital Mohammed V, Faculty of Medicine and Pharmacy Rabat and Mohammed V University Rabat 6203, Morocco

a r t i c l e

i n f o

Article history:
Received 13 October 2016
Received in revised form 31 October 2016
Accepted 1 November 2016
Available online xxxx

a b s t r a c t
We describe a 44-year-old man who developed akinetic mutism following a cerebrovascular accident involving
his left middle cerebral artery. We discuss this rare condition and its unusual clinical picture.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction
Akinetic mutism is a clinical syndrome with both neurological and
psychiatric symptoms. Medical imaging has an important role: it confirms a suspected diagnosis. We report a case of ischemic stroke with
a psychiatric presentation.

control CT scan realized after 72 h. Total resolution of the hemorrhagic
infarction was obtained 10 days after.
The clinical outcome was favorable with partial recovery of speech
and complete recovery of motor deficit at 30 days. The patient was
discharged under medical and psychological treatment and was scheduled for mitral valve replacement surgery.
3. Discussion

2. Observation
A 44 years old single man, right-handed, with no medical history
was brought by his colleague to the emergency department. He found
him at home, silent and motionless. As the patient is living alone, the
time to onset of symptoms cannot be specified. Physical examination
found a conscious patient, apathetic, akinetic, in aphasia with right
hemiparesis listed at 2/5 at lower limbs and 1/5 at upper limbs. The
Babinski sign was positive on the right foot. The patient did not respond
to visual or auditory or verbal commands. Cardiovascular examination
revealed an irregular rhythm associated to a B1 boom at the mitral
valve and a diastolic murmur. Blood pressure was at 132/80 mm Hg.
A cerebral CT scan objectified an ischemic stroke in the territory of
the left middle cerebral artery (MCA) with a mass effect on the ipsilateral ventricle, without any signs of commitment (Fig. 1A & B). The electrocardiogram (ECG) found a heart rate at 90 c/min with atrial
fibrillation and a complete right bundle branch block. A chest X-ray
has noted a bilateral hilar overload without cardiomegaly. Echocardiography objectified a tight mitral stenosis with a surface of about 1 cm2.
The ejection fraction was estimated at 45%, and pulmonary hypertension to 37 mm Hg.
The patient was hospitalized in the cardiac intensive care unit where
he received Salicylates, Enoxaparin and Simvastatin. The evolution was
marked by the occurrence of hemorrhagic infarction found at the
⁎ Corresponding author.
E-mail address: sazi26@hotmail.fr (S. Zidouh).

Akinetic mutism refers to a syndrome characterized by a significant
reduction of about all motor functions including facial expressions, gestures and verbal flow. There is a considerable variation in the clinical
presentation of this type of patient. This variation corresponds more
to a cerebral localization of lesions than the causal disease itself [1].
Akinetic mutism can be diagnosed wrongly as depression, delirium
tremens or Looked-in-syndrome [2]. In our case, as if our patient is living alone, is silent and have a lack of interest, those symptoms could
pass for depression.
Although depression is a common problem of patients suffering
from stroke, akinetic mutism as a state of avolition in which the patient
does not desire to think, to speak or to move [3], it can be presented as a
blunting of expressions, apathy and speech disorder. So it is important
to distinguish the two diagnoses because the treatment is radically different [2].
This perfectly describes the clinical picture encountered as well as in
our case and in literature. In terms of stroke, responsible of mutism, unilateral lesions are rare. They may touch as well as anterior cerebral artery, thalamic or mesencephalic territory and even the internal
capsule [4-5,6]. However in our case, ischemic stroke was unilateral.
Pharmacological treatment may include dopaminergic agents such
as Bromocriptine, Levodopa or Pergolide. These agents are the cause of
spectacular clinical improvements [7]. Non-pharmacological treatment
includes an intense rehabilitation, with modification of the patient's environment to stimulate and increase his interest. Cognitive and behavioral therapies are also suggested [8].

http://dx.doi.org/10.1016/j.ajem.2016.11.008
0735-6757/© 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Zidouh S, et al, Akinetic mutism revealing an ischemic stroke, American Journal of Emergency Medicine (2016), http://
dx.doi.org/10.1016/j.ajem.2016.11.008

2

S. Zidouh et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx

Fig. 1. Ischemic stroke at the left middle cerebral artery (MCA) “A” with a mass effect on the ipsilateral ventricle “B”.

Our patient benefited from rehabilitation measures, and anticoagulant therapy for ischemic stroke. This enabled a partial recovery of his
deficit.
4. Conclusion
Akinetic mutism discovered in a patient without psychiatric history poses a problem of border between the psychiatric and neurological origin. Given the rarity of this disease, and a few
randomized studies available on the subject, imagery remains the
angular point for diagnostic orientation in these situations, in
which the therapeutic management must pass by psychological
rehabilitation.

[2] Nagaratnam N, Nagaratnam K, Ng K, Diu P. Akinetic mutism following stroke. J Clin
Neurosci 2004;11(1):25–30.
[3] Lim YC, Ding CSL, Kong K. Akinetic mutisme after right internal watershed infarction.
Singap Med J 2007;48(5):466.
[4] Meador KJ, Watson RT, Bowers D, Heilman KM. Hypometria with hemispatial and
limb motor neglect. Brain 1986;109:293–305.
[5] Damasio AR, Vandstensen GW. Structure and function of the supplementary motor
area. Neurology 1980;30:300–59.
[6] Benoke R, Rothwell JC, Duk JRP, et al. Performance of simultaneous motor acts in normal subjects and in patients with Parkinson's disease. Brain 1986;46:1024–7.
[7] Marin RS, Wilkosz PA. Disorders of diminished motivation. J Head Trauma Rehabil
2005;20:377–88.
[8] Psarros T, Zouros A, Coimbra C. Bromocriptine-responsive akinetic mutism following
endoscopy for ventricular neurocysticercosis. Case report and review of the literature.
J Neurosurg 2003;99:397–400.

References
[1] Cairns H, Oldfield HC, Pennybaker JB, Whineridge D. Akinetic mutism with an epidermoid cyst of the third ventricle. Brain 1941;34:273–90.

Please cite this article as: Zidouh S, et al, Akinetic mutism revealing an ischemic stroke, American Journal of Emergency Medicine (2016), http://
dx.doi.org/10.1016/j.ajem.2016.11.008