Akinetic mutism and bilateral anterior cerebral artery occlusion

A 43-year-old woman suffered a blast-type injury to the head and neck. She subsequently developed bilateral internal carotid artery occlusion and bilateral anterior cerebral artery infarction not demonstrated by magnetic resonance imaging scan 24 hours after the explosion, but confirmed by a second scan 8 days after the explosion. In patients with blast-type injury to the head and neck who develop coma with a nonfocal neurological exam, the possibility of bilateral carotid artery occlusion and bilateral ischemic infarction should be considered.C arotid artery occlusion is a well-recognized, although infrequent, complication of nonpenetrating trauma to the head and neck.We report a patient who suffered a blast-type injury to the head and neck and subsequently developed bilateral internal carotid artery occlusion and bilateral anterior cerebral artery infarction. Case ReportA 38-year-old woman with a history of mild hypertension and Graves' disease was preparing Christmas dinner for her family when, in attempting to light her gas stove, the stove exploded, producing minor burns to her neck, face, and scalp. There was no loss of consciousness. She was noted initially to be fully alert and neurologically intact, with first-and seconddegree burns on the face, ears, scalp, posterior neck, and upper back estimated to cover approximately 4% of the total body surface area. Eleven hours after the explosion, she became acutely unresponsive and developed episodic decerebrate posturing with episodic hypertension. She had slow roving conjugate eye movements, normal pupillary reaction, normal funduscopic examination, and symmetric lower cranial nerve function. Bilateral limb hypertonia, hyperactive reflexes, and extensor toe signs were present.Emergency computed tomogram of the head with and without contrast was normal. An electroencephalogram showed mild diffuse slowing. Intracranial pressure, cerebrospinal fluid profile, screens

Section: Discussionmentioning

confidence: 99%

Bilateral anterior cerebral artery infarction resulting from explosion-type injury to the head and neck.

Lipschutz

Pascuzzi

Bognanno

et al. 1991

“…16 This diagnosis was supported by "Tc-HMPAO SPECT, which revealed bilateral hypoperfusion in the territory of the anterior cerebral artery. 6 From the point of view of functional neuroimaging, the "horseshoe" image shown on 99m Tc-HMPAO SPECT of the brain, performed on day 2 of admission, greatly contributed to the diagnosis of bilateral infarction in the territory of the anterior cerebral artery.…”

Section: Discussionmentioning

confidence: 99%

Bilateral infarction in the anterior cerebral artery vascular territory due to an unusual anomaly of the circle of Willis.

Borggreve

Deyn

Mariën

et al. 1994

Background Bilateral infarction in the anterior cerebral artery vascular territory is rare and usually results from rupture of an aneurysm of the anterior communicating artery. In the case of an anomaly of the anterior part of the circle of Willis, thrombosis also may lead to bilateral infarction.Case Description A 73-year-old right-handed man presented with a complete loss of communicative behavior and an almost complete quadriplegia.99m Tc-hexamethylpropyleneamine oxime single-photon emission-computed tomography (HMPAO SPECT) of the brain showed a "horseshoe" image, reflecting bilateral perfusion defects in areas supplied by the anterior cerebral arteries. Postmortem examination of the brain revealed an unusual anomaly of the circle of Willis in B ilateral infarction in the anterior cerebral artery vascular territory is very rare 1 and usually results from rupture of an aneurysm of the anterior communicating artery or from thrombosis of the precommunicating part of the anterior cerebral artery in combination with an agenesis of the contralateral part. 2 We present a patient in whom bilateral infarction occurred because of thrombosis of the postcommunicating part of the left anterior cerebral artery and in whom the postcommunicating part of the right anterior cerebral artery was absent. Case ReportA 73-year-old right-handed man was admitted to the hospital after he was found at home sitting in a chair in a verbally unresponsive state and unable to move a single limb. According to his daughter, he had experienced several transient episodes of weakness alternating in both legs during the weeks before admission. On admission the patient looked around and frowned when he was spoken to. He did not react differently to verbal commands and made no attempts to speak or utter sounds. Neurological examination revealed flaccid right hemiplegia, flaccid plegia of the left leg, and paresis of the left arm with an intact grip function of the hand.

“…This lesion, being uncommon, has pro vided an opportunity for some elegant clinical and pathological reports. [1][2][3] The reasons for this infrequency of anterior cerebral artery occlusions has not attract ed much comment; studies have focused upon the vas cular territories and variations of the anterior cerebral artery [4][5][6] and on the symptomatology of its occlu sion. 278 No significant difference, pathologically, of the involvement of the anterior and middle cerebral arteries by an atheromatous process has been suggest ed to explain the different incidence of these occlu sions.…”

mentioning

confidence: 99%

Occurrence and mechanisms of occlusion of the anterior cerebral artery.

Gács¹,

Fox²,

Barnett³

et al. 1983

SUMMARY Occlusion of the anterior cerebral artery is a rare condition. A review of CT scans from 413 patients with ischemic infarction confirmed this, low relative incidence: only 3% of CT scans evidencing infarction involved the territory of the anterior cerebral artery.Four major mechanisms of anterior cerebral artery occlusion have been identified in this series:(1) Emboli in unusual hemodynamic circumstances such as patients presumed to have increased flow through the anterior communicating artery because of unilateral internal carotid artery occlusion. (2) Propagation of thrombotic material from an occluded internal artery into the intracranial branches. ISOLATED OCCLUSION of the anterior cerebral ar tery is rare. This lesion, being uncommon, has pro vided an opportunity for some elegant clinical and pathological reports.1-3 The reasons for this infrequency of anterior cerebral artery occlusions has not attract ed much comment; studies have focused upon the vas cular territories and variations of the anterior cerebral artery [4][5][6] and on the symptomatology of its occlu sion. 278No significant difference, pathologically, of the involvement of the anterior and middle cerebral arteries by an atheromatous process has been suggest ed to explain the different incidence of these occlu sions. 9On the other hand, a striking similarity was found by Gacs and co-workers between the distribu tion of occlusions in various cerebral arteries and the statistical regularity of the pathway of balloons used in superselective angiography. 10"Balloon emboli" oc curred in the anterior cerebral artery in the same pro portion to the middle cerebral artery as did spontane ous occlusions observed by angiography and presumed to be predominantly embolic. Indeed, this similarity provides a substantial contribution to the hypothesis that most intracranial arterial occlusions are of embolic origin.A review of the clinical and radiological case mate rial of University Hospital, London, Ontario, was car ried out to confirm the validity of this distribution pattern. Additional facts concerning the occurrence and the pathogenesis of anterior cerebral artery occlu sions have emerged from this review. Material and MethodsThe computed tomography (CT) scans and angio grams performed on patients with ischemic cerebro vascular disease were reviewed for the years 1979 to 1981. The correlation between the CT evidence of anterior cerebral artery (ACA) lesions and the cerebral angiographic evidence of ACA occlusive lesions was reviewed.Clinical summaries of the patients in whom the cere bral angiograms detected an occlusion are described. ResultsThe distribution of infarctions seen on CT scan in 413 patients is listed in table 1. Eight of the 13 patients with CT evidence of infarction in the anterior cerebral artery territory had been subjected to angiography and occlusion of the anterior cerebral artery was found in 5. In another 3 patients, angiograms revealed an ACA occlusion without CT evidence of infarction in its terri tory. Case Reports Case...