Neurocase
The Neural Basis of Cognition

ISSN: 1355-4794 (Print) 1465-3656 (Online) Journal homepage: http://www.tandfonline.com/loi/nncs20

Akinetic mutism reversibility after L-dopa therapy
in unilateral left anterior cerebral artery infarction
Guery Deborah, Elodie Ong & Norbert Nighoghossian
To cite this article: Guery Deborah, Elodie Ong & Norbert Nighoghossian (2017): Akinetic mutism
reversibility after L-dopa therapy in unilateral left anterior cerebral artery infarction, Neurocase, DOI:
10.1080/13554794.2017.1319493
To link to this article: http://dx.doi.org/10.1080/13554794.2017.1319493

Published online: 27 Apr 2017.

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Date: 01 May 2017, At: 18:31

NEUROCASE, 2017
https://doi.org/10.1080/13554794.2017.1319493

LETTER

Akinetic mutism reversibility after L-dopa therapy in unilateral left anterior cerebral
artery infarction
Guery Deborah, Elodie Ong and Norbert Nighoghossian
Stroke Unit, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France

Dear editor
Akinetic mutism is a neurological disorder characterized by
diminished voluntary movement, speech, and thought, without disturbance of arousal. This syndrome has been rarely
reported following unilateral anterior cerebral artery infarction. Functional interruption of the dopaminergic pathways
may support clinical symptoms. Clinical reversibility after the
introduction of L-dopa therapy is poorly documented.
A 61-year-old woman with chronic high blood pressure
presented with an acute right-sided weakness. Neurological
examination revealed a right hemiplegia, a severe mutism,
and a global akinesia. She had a grasp reflex with forced
grasping. Magnetic resonance imaging revealed a left anterior cerebral artery stroke involving the sensory, motor,
supplementary motor area, prefrontal, and anterior part of
the cingulate gyrus. Magnetic resonance angiography
revealed a right anterior cerebral artery occlusion with an
A1 segment hypoplasia (Figure 1a(,b)).
L-dopa was introduced 4 days later (62.5 mg three times/daily)
and she recovered gradually, and at day 7, her speech was still
impaired but she was able to repeat small sentences, to give her
name and address. She was less catatonic but motor and sensory
symptoms persisted. Two weeks later, she was more fluent
despite episodic echolalia and semantic paraphasias.

Akinetic mutism is classically related to bilateral infarction
within anterior cerebral artery territory, and unilateral involvement is uncommon. Akinesia and mutism with restriction of
spontaneous activity depend on cingulate gyrus or supplementary motor area lesion (Alexander, Delaney, & Strick,
1990; Combarros, Infante, & Berciano, 2000; Nagaratnam,
Nagaratnam, Ng, & Diu, 2004). This case suggests that the
akinetic mutism caused by anterior cerebral arterial infarct is
closely linked to the perturbation of the subcortical dopaminergic system and the amelioration of the clinical features
concordantly evolved with the restoration of the dopaminergic function. Neurological improvement after the introduction
of L-dopa in akinetic mutism due to anterior cerebral artery
infarction is poorly documented. This improvement may be
inconstant but affects the various symptoms related to the
different circuits involved in neurobehavioral changes (Floel,
Hummel, Breitenstein, Knecht, & Cohen, 2005). Moreover, studies showed that levodopa in patients with chronic stroke
enhanced motor memory formation (Seniów, Litwin, Litwin,
Leśniak, & Czonkowska, 2009) and may improve language
impairment, particularly in patients with anterior lesions
(Yang et al., 2007). Although therapeutic data are limited in
the absence of controlled studies, so far we have identified
three cases of unilateral anterior cerebral artery infarction. A
favorable clinical course was observed in all cases to a varying
degree. The response was obtained at different dosages of
levodopa. This drug seems well tolerated and likely underused
in the presence of this clinical syndrome where few medical
alternatives are available.

Disclosure statement
The authors declare that they have no conflict of interest.

References

Figure 1. Magnetic resonance imaging flair sequence: Left anterior cerebral artery
stroke involving the sensory, motor, supplementary motor area and cingular cortex.

CONTACT Norbert Nighoghossian

norbert.nighoghossian@chu-lyon.fr

© 2017 Informa UK Limited, trading as Taylor & Francis Group

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