American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print DOI: 10.1097/PHM.0000000000000884 Abulia due to injury of the prefrontocaudate tract in a stroke patient Sung Ho Jang, MD TE University D Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam Mailing Address: Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Taegu, 705-717, Republic of Korea FAX: 82-53-625-3508 e-mail: strokerehab@hanmail.net EP Tel: 82-53-620-4098 C (Corresponding author): Young Hyeon Kwon, Bs A C Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University Mailing Address: Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu, 705-717, Republic of Korea e-mail: kyh7648764@daum.net 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Acknowledgements This work was supported by the DGIST R&D Program of the Ministry of Science, ICT and Future Planning (17-BD-0401). Disclosures D Financial disclosure statements have been obtained, and no conflicts of interest have been A C C EP TE reported by the authors or by any individuals in control of the content of this article. 2 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. A 54-year-old male underwent conservative management at a university hospital for intraventricular and intracerebral hemorrhages in both frontal lobes (Fig.1-A). At three months after onset, he was admitted to the rehabilitation department of our university hospital, and exhibited severe abulia. He could carry out only some activities of daily life by himself, such as water drinking, eating when meals were served, toileting when someone brought him to the D bathroom, toothbrushing when toothbrush with toothpaste was supplied. In addition, he could speak only a few sentences by himself; for example, “what are you doing” and “I want to go TE bathroom”. Brain MRI at three months after onset showed leukomalactic lesions in the left frontal lobe including the left caudate nucleus (CN)(Fig. 1-B). EP Fig.1 Diffusion tensor imaging data were acquired at three months after onset using a 6-channel C head coil on a 1.5 T Philips Gyroscan Intera (Hoffman-LaRoche, Best, Netherlands). For reconstruction of the connectivity of the CN, the seed region of interest was given at the CN that A C was isolated using adjacent structures (medial boundary: the lateral ventricle, lateral boundary: the anterior limb of the interal capsule. On diffusion tensor tractography (DTT), discontinuations of the neural connectivity between the CN and the medial prefrontal cortex (Broadmann area [BA]: 10 and 12) and the orbitofrontal cortex (BA: 11 and 13) were observed in both hemispheres (Fig. 1-C). In this study, the patient showed discontinuations of the neural connectivity between the CN and the medial prefrontal cortex and orbitofrontal cortex in both hemispheres. These results 3 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. indicated severe injuries of both prefrontocaudate tracts. Abulia, which is a milder condition of akinetic mutism, is characterized by a lack of initiative, spontaneity, and drive, and by apathy, slowness of thought, and blunting of emotional responses and responses to external stimuli.1 Bilateral disruption of the frontosubcortical circuit, especially the neural tract connecting to the medial prefrontal cortex, has been suggested as a pathogenic mechanism of demotivational D conditions, such as akinetic mutism and abulia.2,3 Based on our results, this patient’s abulia was TE ascribed, at least in part, to bilateral injury of the prefrontocaudate tract. In conclusion, injuries of the prefrontocaudate tract were demonstrated in a patient who showed abulia following intraventricular and intracerebral hemorrhages. Our results suggest that EP DTT-based evaluation of the frontosubcortical circuit would be useful for stroke patients who A C C exhibit demotivational signs. 4 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Reference 1 Larner AJ: A dictionary of neurological signs : Clinical neurosemiology. Dordrecht ; Boston: Kluwer Academic Publishers; 2001. 2 Mega MS, Cohenour RC: Akinetic mutism: Disconnection of frontal-subcortical circuits. Neuropsychiatry Neuropsychol Behav Neurol 1997;10:254-259. Jang SH, Kwon HG: Apathy Due to Injury of the Prefrontocaudate Tract Following Mild D 3 A C C EP TE Traumatic Brain Injury. Am J Phys Med Rehabil 2017 Jul;96(7):e130-e133. 5 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Figure legend Fig. 1 (A) Brain computed tomography images at seven days after onset show intracerebral hemorrhage in both frontal lobes and intraventricular hemorrhage. (B) T2-weighted brain magnetic resonance images at three months after onset show leukomalactic lesions in the left D frontal lobe. (C) On 3-month diffusion tensor tractography, discontinuations (arrows) in neural A C C EP visible in both hemispheres. TE connectivity between the CN and the medial prefrontal cortex and the orbitofrontal cortex are 6 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. A C C EP TE D Figure 1 7 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.