Case Reports / Journal of Clinical Neuroscience 64 (2019) 29–32

29

Fig. 3. (A) Subsequent Axial 2D time-of-flight MRA, demonstrated persistent medial displacement and rotation of the ICA (arrow) with the head in a neutral position. (B) MRI:
Axial T1-weighted imaging, head turned to the right, demonstrated restoration of the normal anatomic position of the ICA (arrow).

able considering the minimal morbidity and allows the patient
physical and psychological freedom with neck movement.
4. Conclusion
Hyoid bone impingement of the carotid artery should be considered in stroke of indeterminate aetiology especially in the presence of neck, throat, ear pain, repetitive neck movements and
prolonged neck position. CTA neck with head rotation may be used
for initial screening.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jocn.2019.03.040.

References
[1] Hart RG, Catanese L, Perera KS, et al. Embolic Stroke of Undertermined Source: A
systematic review and clinical update. Stroke 2017;48(4):867–72.
[2] Mirjalili SA, McFadden SL, Buckenham T, et al. Vertebral levels of key landmarks
in the neck. Clin Anat 2012;25(7):851–7.
[3] Lee W. General principles of carotid Doppler ultrasonography. Ultrasonography
2014;33(1):11–7.
[4] Ludt C, Leppert M, Jones A, et al. Multiple strokes associated with elongation of
the hyoid bone. Neurohospitalist 2018;8(1):35–7.
[5] Renard D, Rougier M, Aichoun I, et al. Hyoid bone-related focal carotid
vasculopathy. J Neurol 2011;258:1540–1.
[6] Renard D, Freitag C. Hyoid-related internal carotid artery dissection. J Neurol
2012;259:2501–2.
[7] Kinoshita N, Saito K, Yamaguchi Y, et al. Flip-flop phenomenon: swallowinginduced arterial displacement as an indicator of carotid artery disease.
Cerebrovasc Dis 2018;45(5–6):258–62.
[8] Robinson PJ, Davis JP, Fraser JG. The hyoid syndrome: a pain in the neck. J
Laryngol Otol 1994;108:855–8.

https://doi.org/10.1016/j.jocn.2019.03.040

Mirror writing after perimesencephalic subarachnoid haemorrhage
Benjamin Fleming a,⇑, Alexios A. Adamides a,b
a
b

Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Department of Surgery, University of Melbourne, Victoria, Australia

a r t i c l e

i n f o

Article history:
Received 13 March 2019
Accepted 21 March 2019

Keywords:
Mirror-writing
Mirror writing
Perimesencephalic subarachnoid
hemorrhage
Non-aneurysmal subarachnoid hemorrhage
Delayed ischemic neurological deficit
Hyponatremia

a b s t r a c t
We report a case of a right-handed Caucasian woman who developed mirror writing following a nonaneurysmal, non-traumatic subarachnoid haemorrhage. The patient was unaware of having this phenomenon, and it was detected by clinical staff when the patient was writing a card to a family member.
Serial imaging has ruled out a stroke as well as an underlying vascular abnormality. This phenomenon
resolved after two months. Whilst there is a body of literature surrounding mirror writing, to our knowledge, this is the first description of mirror writing in the setting of a perimesencephalic subarachnoid
haemorrhage.
Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.

⇑ Corresponding author at: Department of Neurosurgery, The Royal Melbourne
Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia.
E-mail address: Benjamin.fleming@mh.org.au (B. Fleming).

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Case Reports / Journal of Clinical Neuroscience 64 (2019) 29–32

1. Case summary
A 59-year-old right-handed Caucasian woman presented with
sudden onset, severe, thunderclap headache and vomiting. Computer tomography (CT) of the head revealed moderate volume subarachnoid blood within the interpeduncular, ambient, prepontine,
and medullary cisterns, extending into the suprasellar cistern
and proximal left sylvian fissure, and a small haematoma within
the foramen of Magendie (Fig. 1).
At the time of admission, she had a Glascow Coma Scale (GCS)
score of 14/15, with eye-opening to voice, but no neurological
deficit. The patient was an active smoker, and had a known history of treated breast cancer. There was no history of trauma.
She had completed high school education and worked as a
counsellor.
Blood pressure remained well controlled throughout her admission, and she never exhibited weakness or sensory disturbance. CT
angiogram as well as Digital Subtraction Angiogram (DSA), performed on the day of admission did not show an aneurysm or other
vascular lesion. On day 3 of admission, she developed Syndrome of
inappropriate ADH release (SiADH), with a sodium nadir of
120 mmol/L. This was managed with hypertonic saline, improving
to 127 mmol/l over 24 h and 135 mmol/L at another 48 h.
MRI/MRA of the brain and cervical spine on day 3 showed a
small focal acute infarct within the right occipital subcortical white
matter but no evidence of vasospasm or underlying vascular lesion.
An MRI/A brain performed one week later demonstrated incidental
focal narrowing of the right P1 segment, likely due to vasospasm.
The previous focal occipital infarct was not visible.
During her admission, she had regular occupational therapy
reviews, scoring 12/30 on the Montreal Cognitive Assessment
tool (Fig. 2). Major deficits were visuospatial, memory, language
and orientation, with numbers on the clock-face task running in
an anticlockwise order but the numbers not being mirrored. On
day 12 of admission, she was noted to have more pervasive
mirror writing when writing a card (Fig. 3). A brain CT angiogram demonstrated basilar as well as bilateral P1 segment
narrowing.

Fig. 1. CT brain on the day of admission, demonstrating subarachnoid blood within
the basal cisterns.

Serial imaging since her hospital discharge remains unremarkable. Over the following two months, she became increasingly
aware of her mirror writing, and it resolved.

2. Discussion
Mirror writing is an unusual script, in which text runs in the
opposite direction to normal and with letters reversed [1,2]. When
held to a mirror, such words can be read normally. The phenomenon itself is highly heterogenous, with writing ranging from
a single reversed letter, through numerous reversed letters but
not words, to occasional mirrored words, and even complete pages
of script [2]. Numerals and visual engrams may also be reversed
too.
In otherwise healthy individuals, the phenomenon is seen, for
example, in children who are learning to write, as well as in
right-handed adults when they are required to write with their
unaccustomed hand [3]. It is almost always undertaken with the
left hand [2], with left-handed individuals and those whose languages are written leftwards, such as Japanese, Chinese, Hebrew
and Arabic, tending to exhibit more this phenomenon [2,3].
Pathological mirror writing is mostly commonly seen in the setting of stroke. However, even then, the incidence is low, with
reports varying between 2.5 and 13 percent, and almost invariably
involves damage to the left hemisphere. Other circumstances in
which mirror writing can manifest is in focal or diffuse brain
trauma, and degenerative brain diseases such as Parkinson’s disease and spinocerebellar degeneration [2,4]. Given the variety of
conditions in which this phenomenon can manifest, it is clear that
there is no single structure involved. Indeed, mirror writing has
been reported in patients with isolated lesions involving, right supplementary motor area, medial prefrontal cortex, anterior cingulate gyrus, left basal ganglia and left parietal lobe [2,5–11].
Multiple theories exist regarding why mirror writing can
develop, ranging from motor centre, spatial-orientation, visual,
and thalamo-cortical circuitry hypotheses [6,12]. However, the
unifying feature of these is that mirror writing is almost always
carried out with the left hand, and is often associated with other,
more pervasive phenomena, such as mirrored reading, right-left
perceptual difficulties, and dyslexia [6,12]. Our case is unique in
that our patient exhibited mirror writing with the right hand,
and without other features such as mirrored reading or mirrored
engrams.
Whilst our patient did exhibit a delayed ability to differentiate
left from right, overall, she was correct in her responses such as
naming various left- and right-sided body parts. The most notable
example of her left right disorientation was during her completion
of the clock-face drawing task on the Montreal Cognitive Assessment tool, whereby numbers were ordered in an anticlockwise
direction but the numbers themselves were not mirrored. She
was still able to copy a cube in the conventional fashion. It is difficult to determine whether other objects she drew were mirrored,
as those witnessed, such as hearts and crosses, have lines of symmetry. The patient also was able to read in the conventional Western fashion. She also exhibited anosophnosia and anosdiaphoria
regarding her writing. However, interestingly, over two months,
her mirrored writing became less frequent as she became increasingly aware of and concerned by this trait.
Both the cause of her subarachnoid haemorrhage and mirrored
writing remains uncertain. However, the radiology findings of basilar artery and proximal P1 segment narrowing, concerning for
vasospasm, could suggest that the patient’s mirror writing was
due to cerebral ischaemia. Interestingly, the patient developed profound hyponatraemia early during her admission (day 3). Several
studies have demonstrated an association between hyponatraemia

Case Reports / Journal of Clinical Neuroscience 64 (2019) 29–32

Fig. 2. Our patient’s Montreal Cognitive Assessment (MOCA), demonstrating deficits across multiple cognitive domains.

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Case Reports / Journal of Clinical Neuroscience 64 (2019) 29–32

Declarations of interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jocn.2019.03.039.
References

Fig. 3. A handwritten card from the patient, noted on day 12 of admission.

and delayed ischaemic neurological deficits, which can include features as subtle as mental state changes [13–17].
This case outlines an interesting, rare and transient phenomenon in a right-handed patient after a perimesencaphlic subarachnoid haemorrhage. To our knowledge this is the first
reported such case in the literature.
Disclosure
This report did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors. The
authors have no conflicts of interest to disclose.
Sources of support
This report did not receive any funding from funding agencies in
the public, commercial, or not-for-profit sectors.
https://doi.org/10.1016/j.jocn.2019.03.039

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