Episodically Remitting Akinetic Mutism Following Subarachnoid Hemorrhage
Abstract
CASE REPORTB., a 52-year-old former electrician, was admitted to the psychiatry service with an absence of spontaneous activity. He had been well, with no psychiatric or medical history, until at age 48 he suffered a ruptured basilar artery aneurysm, which was surgically treated. The patient was comatose for approximately 4 weeks, then gradually regained consciousness. Rehabilitation brought return of his strength, stamina, and ability to ambulate. He was left, however, without volitional activity.Seventeen months later, the patient's wife reports that he experienced his first “awakening.” B.'s mental status erupted into its premorbid state, with full return of his demeanor and affect just as they were before the stroke. He was inquisitive about changes in his life, specifically the sale of his beloved fishing boat, but would not believe he had suffered a stroke. After sleeping through the night, the patient was once again akinetic and mute.After another year, the patient had his first grand mal seizure. Within 3 days, his persona emerged again. Four more times over the next year his affect returned on the heels of a seizure. The potential connection led the patient's wife to seek psychiatric evaluation for possible ECT and to stop his phenytoin.Upon admission, the patient would respond to questions and follow simple commands, but he initiated no spontaneous action. He stayed where placed, with no effort to move, eat, or toilet himself. He would stare blankly and emotionlessly at nothing, with his hands always placed on his thighs. Neurologic examination revealed a deficit in downward gaze bilaterally and hyperactive patellar reflexes. He walked with a parkinsonian gait and minimal arm swing, but there was no tremor. There was no other abnormality of strength or sensation, and he exhibited no pathological reflexes. Cognitively, the patient was able to score 20 out of 30 on the Mini-Mental State Examination, losing points on orientation and recall.Formal neuropsychological testing included Wechsler Adult Intelligence Scale–Revised, Object Memory Selective Reminding Test, Boston Naming Test, Controlled Oral Word Association Test, Visual Organization Test, and Apraxia Screening Exam. These revealed extremely impaired cognitive function. Verbal IQ was in the low normal range, fund of general information was below average, and verbal abstraction was poor. Object-naming memory was not preserved, and generative naming was extremely impaired. The patient showed severe impairment for recent memory and reduced speed of information processing.CT scan showed postoperative changes along with encephalomalacic changes in the right temporal pole and chronic ischemic focal changes in the basal ganglia bilaterally and in the left thalamus. There was no hydrocephalus. EEG was abnormal, with slow occipital rhythm and background activity suggesting a mild, diffuse disturbance in cerebral function. There was also a focal disturbance in the right temporal region consisting of intermittent, low-voltage slow activity, but no epileptiform activity.A cerebral angiogram revealed a residual, 3–4-mm aneurysm at the basilar tip. It was therefore considered unsafe to proceed with ECT for fear of inducing another hemorrhage. Medical management was attempted with trials of bromocriptine, methylphenidate, and parenteral lorazepam. These brought no clinical improvement and had significant side effects.After careful consideration, the patient's wife elected to proceed with intravascular embolization of the residual aneurysm to allow a trial of ECT. Of note was another arousal, which occurred postoperatively. This episode was preserved on videotape.Almost 3 years after the initial stroke, B. was admitted to this institution for a trial course of ECT. Six convulsions were induced over a 2-week period. After the first two, the patient awakened much as before. Unfortunately, he returned to his akinetic mute state for the remainder of the hospitalization despite the ongoing ECT. At discharge, there was little change from his first admission 7 months earlier.
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