RESIDENT & FELLOW SECTION Teaching Video NeuroImage: Isolated Undulating Tongue Hyperkinesia Following a Basilar Stroke Daniel A. Santos, MD, Felipe O. Costa, MD, MSc, Henrique N. Dourado, Jackson A. Ferreira, MSc, and Humberto Castro-Lima, PhD ® Neurology 2024;102:e208079. doi:10.1212/WNL.0000000000208079 Correspondence Mr. Dourado henriquedourado19.1@ bahiana.edu.br Figure Patient’s Neuroimaging Downloaded from https://www.neurology.org by 138.199.53.243 on 18 April 2024 Cerebral angiotomography shows occlusion of the distal portion of the basilar artery (A). Sagittal section of the followup head CT shows hypodensity affecting the midbrain and part of the pons (B). Axial section of the follow-up head CT shows hyposdensity mainly affecting the right thalamocapsular region (C). An 82-year-old man with a history of hypertension and coronary revascularization presented with sudden-onset right hemiparesis and disorientation lasting 5 hours. On admission, he was intubated because of gasping and a Glasgow Coma Scale of 3. Hemorrhagic stroke was suspected, but ruled out by the initial head CT, which revealed old cerebellar lacunae. The following day, the comatose, now unsedated patient exhibited tetraparesis; fixed, nonreactive pupils; and corneal reflex, but no oculocephalic reflex. Rhythmic undulating tongue movements without palatal or limb involvement were first observed (Video 1). EEG revealed no epileptiform activity. Follow-up head CT showed acute ischemic lesions in the thalamocapsular region, midbrain, and pons while angiotomography revealed distal basilar artery occlusion (Figure). Involuntary tongue movements, though rare, have been associated with various conditions such as stroke, trauma, and epilepsy.1,2 These movements may result from disinhibition within the inhibitory reticular formation projecting to hypoglossal neurons, suggesting the pontine reticular formation as a central pacemaker.2 MORE ONLINE Video For multiple-choice questions relevant to Teaching NeuroImages and Teaching Video NeuroImages, find @greenjournal on X using the hashtag #NeurologyRF Author Contributions D.A. Santos: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. F.O. Costa: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design. H.N. Dourado: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data. J.A. Ferreira: major role in the acquisition of data. H. Castro-Lima: drafting/revision of the manuscript for content, including medical writing for content. From the Neuroscience Center (D.A.S., F.O.C., H.N.D., H.C.-L.), Bahiana School of Medicine and Public Health, Salvador; Departments of Neurology (D.A.S., F.O.C.) and Radiology (J.A.F.), Suburban Hospital, Salvador, Bahia, Brazil. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Copyright © 2023 American Academy of Neurology Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. 1 Study Funding The authors report no targeted funding. handling editor was Resident & Fellow Section Deputy Editor Katherine Fu, MD. Disclosure The authors report no relevant disclosures. References Publication History 2. Postert Th, Amoiridis G, Pöhlau D, Hoffmann V, Przuntek H. Episodic undulating hyperkinesias of the tongue associated with brainstem ischemia. Mov Disord. 1997;12(4):619-621. Available at: onlinelibrary.wiley.com/doi/10. 1002/mds.870120429 Lee PH, Yeo SH. Isolated continuous rhythmic involuntary tongue movements following a pontine infarct. Parkinsonism Relat Disord. 2005;11(8):513-516. doi: 10.1016/j.parkreldis.2005.07.002 Downloaded from https://www.neurology.org by 138.199.53.243 on 18 April 2024 Received by Neurology July 11, 2023. Accepted in final form October 26, 2023. Submitted and externally peer reviewed. The 1. 2 Neurology | Volume 102, Number 3 | February 13, 2024 Neurology.org/N Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.