Parakinesia Brachialis Oscitans: A Case Report

Abstract

A 51-year-old man was admitted to the emergency room with an 8-hour history of sudden right hemiparesis. On examination, right upper extremity strength was graded as 1 proximally, 2 distally, 3 for the lower limb, and there were also right central facial paralysis and motor aphasia. He had a previous medical history of hypertension, dyslipidemia, type 2 diabetes, obesity, and a stroke 3 years before with mild residual right hemiparesis. A head CT showed a large fronto-parieto-temporal hypodense area consistent with a left middle cerebral artery (MCA) territory stroke (Fig. 1). A Doppler ultrasound of the carotid and vertebral arteries revealed occlusion of the left internal carotid artery. Arteriography confirmed the left MCA occlusion and revealed two critical intracranial stenosis in the right internal carotid artery. Electrocardiogram showed a slow atrial fibrillation, and an echocardiogram revealed a left ventricular intracavitary thrombus. Before admission, he was on acetyl salicylic acid 100 mg daily, subcutaneous regular insulin 30 U twice-daily, losartan 50 mg daily, and simvastatin 40 mg daily.After approximately 48 hours of admission, he developed patterned involuntary movements in the right upper limb during yawning. The movements, as shown in the video segment (see Video 1), consisted of simultaneous lifting of the entire right upper limb associated with tremor. Upon cessation of yawning, the limb returned to its resting, paretic position. The movement reoccurred continuously with every yawn, and during the episodes, the level of consciousness was preserved, as it was between them. The phenomena ceased spontaneously 12 hours after they were first noticed.The patient remained with the same neurological deficits throughout admission. He underwent proximal and distal right internal carotid artery angioplasty and subsequent anticoagulation targeting the intracavitary thrombus. Unfortunately, after a 2-month hospital stay complicated by recurrent episodes of pulmonary and urinary tract sepsis, the patient died as a result of septic shock.Here, we describe the phenomenon termed parakinesia braquialis oscitans (PBO), recently proposed by Walusinski et al.1 Descriptions of PBO are quite consistent, with jaw opening during the yawn, accompanied by elevation of the paretic limb, and subsequent drop upon ending the movement. 1-3 This phenomenon typically occurs in the upper limbs and may be associated with milder concomitant movement of the lower extremity. In terms of localization of the correspondent brain injury, PBO has been associated with lesions that affect the internal capsule, and basal ganglia and their connections, ranging from cerebrovascular, demyelinating, infectious, and expansive lesions. From a timing perspective, most cases are acute; however, they have been described even within 6 months of the injury. 4Yawning is a stereotyped, involuntary, and repetitive movement observed in almost all vertebrates. 4 It is believed that the paraventricular nucleus in hypothalamus plays a role in yawning, as...

Parakinesia Brachialis Oscitans – a Rare Post-Stroke Phenomenon

“…In one of the reported cases [3], there was tremor associated with the movement. In another reported case, patient could perform complex purposeful act during movement and also could wilfully supress it [4].…”

“…Yawning is a physiological phenomenon seen in almost all vertebrates. The paraventricular nucleus of hypothalamus plays the key role in yawning through its connections with hippocampus and brain stem areas such as reticular formation and locus coeruleus [3]. The final executive pathway of yawning involves motor nuclei of cranial nerves V, VII, IX, XI and XII and C1-C4.…”

On the Emergence of Tremor in Prodromal Parkinson’s Disease

“…However, involuntary movement occurring synchronously with yawning has been previously described wherein patients with acute hemiplegia may experience reflex elevation of the paralyzed arm during yawning [56][57][58][59]. This phenomenon of parakinesia brachialis oscitans has been reported in patients with vascular, demyelinating, infectious and degenerative lesions affecting the corticospinal tract, basal ganglia or brainstem and consists of reproducible involuntary elevation or abduction of the paretic limb coincident with jaw opening during yawning [59].…”