Case Report

Full recovery of Akinetic Mutism after corpus callosum
infarction in post subarachnoid hemorrhage of ruptured
distal anterior cerebral artery aneurysm
Ibrahim Alnaami, MSc, FRCSC, Saeed A. Alqahtani, MD, ABPN.

ABSTRACT

‫استعرض املؤلفون في هذا التقرير حالة مريض ذكر سابقًا يبلغ من‬
‫ عا ًما تعرض لنزيف حتت العنكبوتية ومتزق في الشريان‬23 ‫العمر‬
‫ مت عالجه بتقنية اللف داخل‬.‫الدماغي األمامي األمين البعيد‬
‫ بعد بضعة‬.‫ والتي كانت هادئة أثناء اجلراحة‬،‫األوعية الدموية‬
‫ أعرب عن أعراض‬،‫أيام من التهوية امليكانيكية ونزع األنبوب‬
‫الالمباالة والنعاس ونقص احلافز ونقص الوظيفة احلركية التلقائية‬
‫ كشف التصوير بالرنني املغناطيسي‬.‫املتوافقة مع خرس الحركي‬
‫ ظل في حالة الصمت‬.‫للدماغ عن احتشاء كامل للجسم الثفني‬
‫ يو ًما قبل أن يبدأ في إظهار التحسن حتى‬21 ‫غير احلركي ملدة‬
‫ أبلغ املؤلفون عن اكتشاف فريد حيث‬.‫ أشهر‬3 ‫تعافى متا ًما في‬
‫نتج اخلرس احلركي عن احتشاء اجلسم الثفني بد ًال من الفص‬
.)‫اجلبهي اإلنسي (التلفيف احلزامي‬
The authors report a previously healthy 23-yearold male patient who presented with subarachnoid
hemorrhage and was found to have a ruptured right
distal anterior cerebral artery aneurysm. He was
treated by endovascular coiling technique, which
was uneventful perioperatively. After a few days of
mechanical ventilation and upon extubation, he
expressed symptoms of apathy, drowsiness, lack of
motivation, and lack of spontaneous motor function
consistent with akinetic mutism. The magnetic
resonance imaging of the brain revealed infarction of
the whole body of corpus callosum. He remained in
akinetic mutism status for twenty-one days before he
started to show improvement until he fully recovered
in 3 months. The authors report a unique finding
where akinetic mutism resulted from infarction of
the corpus callosum rather than medial frontal lobe
(cingulate gyrus).
Neurosciences 2020; Vol. 25 (5): 412-415
doi: 10.17712/nsj.2020.5.20200071
Division of Neurosurgery (Alnaami), Department of Surgery, Division
of Neurology (Alqahtani), Department of Medicine, King Khalid
University, Abha, Kingdom of Saudi Arabia

412 Neurosciences 2020; Vol. 25 (5)

Received 11th May 2020. Accepted 13th July 2020.
Address correspondence and reprint request to: Dr. Ibrahim Alnaami,
Division of Neurosurgery, Department of Surgery, College of Medicine,
King Khalid University, Abha, Kingdom of Saudi Arabia
E-mail: ialnaami@gmail.com
ORCID ID: https://orcid.org/0000-0001-6433-1990

A

kinetic mutism (AM) is a syndrome of psychiatric,
verbal, and motor components. It is a state of
limited responsiveness to the environment in the
absence of gross alteration of sensorimotor mechanisms
operating at a more peripheral level. Neither paralysis
nor coma accounts for the symptoms.1,2 The AM may
result from trauma, infarctions, infections or others.
AM have been rarely reported as a consequence of
aneurysmal subarachnoid hemorrhage. The authors
report a case of young male patient who is previously
healthy, who presented with aneurysmal SAH. He
developed AM as a result of corpus callosum infarction
without involvement of cingulate gyrus. The novel
finding in our study is that infarction did not affect the
cingulate gyrus nor medial frontal lobes. In fact, the
insult was limited to the body of corpus callosum only,
sparing both the genu and the splenium.
Case Report. Patient information and clinical
presentation. A previously healthy 23-year-old male
patient who presented to the Emergency Room with
sudden onset of excruciating headache. On initial
assessment, his Glasgow coma score (GCS) was 14
over 15, with equal reactive pupils bilaterally and no
apparent neurological deficit.

Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.

OPEN ACCESS

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Akinetic mutism … Alnaami & Alqahtani

Figure 2 - Post coiling MRI a) axial T1 FLAIR b) sagittal T2, and c) axial
ADC sequence MRI of the brain revealed infarction of the
whole body of corpus callosum.

Figure 1 - Digital subtraction angiography a) AP view and b) oblique
view of right internal carotid artery injections depicting
right DACA aneurysm. c) axial computed tomography of
the brain prior to coiling andafter external ventricular drain
being inserted (black arrow) showed small area of hypodensity
in corpus callosum (white arrow). d) 3D CT angiography
of cerebral vessels in oblique view, reveled hypoplastic left
anterior cerebral artery (long white arrow) and the aneurysm
(short white arrow).

Diagnostic assessment. In the peripheral hospital,
brain computed tomography (CT) revealed extensive
subarachnoid hemorrhage (SAH) with no significant
hydrocephalus. While completing his workup in the
emergency department, his level of consciousness
rapidly dropped to 8 over 15 with no apparent seizure
attack. He was immediately intubated for airway
protection and started on sedation. The brain CT was
repeated immediately to reassess for presumed aneurysm
re-rupture or obstructive hydrocephalus.
Therapeutic intervention. The repeated image did
not reveal new bleed or worsening of hydrocephalus.
However, the neurosurgeon elected to insert an external
ventricular drain for monitoring and preparation of
transfer to another health-care facility for definitive
treatment. The cerebral computed tomography
angiogram (CTA) revealed a 5x4x4 mm bilobed right
distal anterior cerebral artery aneurysm (DACA)
(pericallosal aneurysm).

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Figure 3 - follow-up angiogram a) AP view shows coils mass inside the
aneurysm, b) and lateral internal carotid artery injection
depicting embolized aneurysm with mild vasospasm in the
distal anterior cerebral artery.

After arrival at our hospital, the patient was moving
all his limbs and opening his eyes only to painful
provocation. He was taken urgently to the angiography
suite. The aneurysm was occluded successfully using
the coiling technique, and there were no intraoperative
complications (Figure 1).
Follow-up and outcome. Postoperatively, he received
standard Intensive Care Unit supportive therapy for a
few days. The neurosurgery team and ICU made the
patient extubated. Upon extubation, the neurological
examination showed that patient eyes were closed.
He did not speak spontaneously. With the painful
stimulation, the patient opened his eyes. He uttered
a few slurred and dysarthric words. In the next few
days, he started to obeying single step commands and
opened eyes spontaneously. He was awake, but the
patient expressed signs of apathy. He demonstrated a
lack of motivation, indifference, and a scarcity of facial
and emotional expressions when interacted with a close
family member during the ICU visits. No abnormal
movements observed, and no grasp reflexes noticed.
Over the next 3 weeks, he had spontaneous speech but

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Akinetic mutism … Alnaami & Alqahtani

Figure 4 - Timeline of the course of the management of 23-year-old male who developed akinetic mutism after rupture of distal anterior cerebral artery
aneurysm.

diminished. He started to have a normal spontaneous
movement in all 4 extremities within the context of
preserved alertness.
Magnetic resonance imaging (MRI) of the brain
showed infarction of the entire body of corpus callosum
(Figure 2). The patient underwent multiple visits to
the angiography suite to check for any possibility of
vasospasm; however, a repeated cerebral angiogram
revealed mild vasospasm in distal anterior cerebral
arteries branches (Figure 3).
Clinically, the patient was not in a coma or decreased
consciousness; he remained in the akinetic mutism

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status for 21 days. We believe that he was in akinetic
mutism due to the persistent presence of apathy, abulia,
lack of motivation, and emotional response, along with
the initial lack of spontaneous speech with preserved
wakefulness. The patient then started to gradually
recover, regaining full speech first then motor function,
until he had complete recovery after three months.
Discussion.
Aneurysmal
subarachnoid
hemorrhage is a well-known medical condition with
devastating consequences such as vasospasm, seizures,

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Akinetic mutism … Alnaami & Alqahtani

hydrocephalus, and others. One of its rarely documented
consequences is akinetic mutism.
Akinetic mutism is a syndrome of psychiatric,
verbal, and motor components. It is a state of limited
responsiveness to the environment in the absence of
gross alteration of sensorimotor mechanisms operating
at a more peripheral level. Neither paralysis nor coma
accounts for the symptoms.1,2
The patients with akinetic mutism cannot speak or
move. These deficits do not result from a direct effect
on motor or speech fibers per se, but from the lack of
neuronal initiative circuitry. From the neuroanatomical
point of view, this syndrome has been classified into
telencephalic, where medial frontal lobes are affected,
diencephalic in which thalamus and basal ganglia are
affected, and mesencephalic, where the upper brainstem
is also affected.
Akinetic mutism may result from trauma, infections,
infarction, carbon monoxide poisoning, hydrocephalus,
post transcallosal approach,2 and others. However, the
first time akinetic mutism was linked to SAH was in
1971.2,3
In 2004, Choudhary concluded the dismal prognosis
of akinetic mutism in post SAH patients. Of the 21
patients reviewed in that study, 2 only had a distal ACA
aneurysm. Later, a few other papers reported akinetic
mutism in DACA.3-5 Apart from the report by Sibille
et al6 2016 all cases of akinetic mutism post SAH in
DACA had a poor prognosis, where patients ended up
with significant disabilities and being dependent or in
vegetative states.
The characteristic finding in the reports above is the
infarction of the medial frontal lobe (cingulate gyrus) or
the presence of hydrocephalus. The novel finding in our
study is that infarction did not affect the cingulate gyrus
nor medial frontal lobes. In fact, the insult was limited
to the body of corpus callosum only, sparing both the
genu and the splenium.
The mechanism in which the authors speculate
the full recovery of the patient's akinetic mutism is
attributed to the fact that only the body of the corpus

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callosum was affected. The patient course was similar
to the transient mutism that results from callosotomy
procedures in refractory epilepsy patients where their
mutism may last up to twenty-five days.6 The patient's
age is also considered a favorable prognostic factor.
In conclusion, the authors report a unique finding
where akinetic mutism resulted from infarction
of the corpus callosum rather than medial frontal
lobe (cingulate gyrus), which followed a rupture of
DACA aneurysm, and a rare complete recovery for
such pathology, where young patient's age played an
important role in this outcome.
Acknowledgement. The authors would like to acknowledge
ProofReadingService.com (www.proofreadingservice.com) for English
language editing.

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management. Elsevier; 2016. p 347-361.
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Reversible akinetic mutism after aneurysmal subarachnoid
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gyri. Case Rep Neurol Med 2016; 2016: 5193825.
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A, Paggi A, et al. Mutism in 36 patients who underwent
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