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Abrupt onset of disturbed vigilance, bilateral third nerve palsy and masturbating behaviour: a rare presentation of stroke

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Abrupt onset of disturbed vigilance, bilateral third nerve palsy and masturbating behaviour: a rare presentation of stroke
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   Abrupt onset of disturbed vigilance,bilateral third nerve palsy andmasturbating behaviour: a rarepresentation of stroke Karl Mondon, Isabelle Bonnaud, Se´verine Debiais, Paul Brunault,Denis Saudeau, Bertrand de Toffol, Alain Autret  The clinical presentation of stroke usually includes sensory–motor impairment, cranialnerve palsies, or cognitive dysfunction. Disorders in behaviour are less frequently seen.The case of a patient with a very disturbing presentation, which included a disturbance in vigilance, bilateral third nerve palsy and masturbating behaviour, is presented. Thetopography of the lesions and its implications on the deficits observed are discussed.  A  48-year-old woman was admittedto the hospital because of an acutedisturbance in vigilance. Thepatient’s medical history included gas-tro-oesophageal reflux disease,Me´nie`re’s disease, breast cancer 2 yearsbefore admission, and chronic mildmood depression. Her current medica-tions included amitriptyline (20 mg/ day), tamoxifen citrate (20 mg/day),and lansoprazole (30 mg/day).On admission her temperature was37.5 ˚ C, blood pressure was 133/ 75 mm Hg and heart rate was 84 beats/ min;theremainingfindingsofthephysi-cal examination were within normallimits. The heart sounds were normal, with no murmur, gallop, or rub. Thepulmonary examination revealed no jugular venous distension and the breathsoundswereequalbilaterally.Theelectro-cardiogramwasinnormalsinusrhythm.On neurological examination, thepatient was in a coma (Glasgow ComaScore 7 (E1V1M5)). There was no loss of motor function and the deep tendonreflexeswerepresent.Therewerenosignsof pyramidal irritation. The ocular exam-inationshowedbilateralthirdnervepalsy with non-reactive mydriasis.The disturbance in vigilance progres-sively improved during the next 7 days,although the bilateral third nerve palsypersisted. Disturbingly, the patientdeveloped motor stereotypes concern-ing her upper (crumpling) and lowerlimbs (rubbing on the floor). In addi-tion, she developed uncontrollablemasturbating behaviour. When she was asked why she did this, sheanswered ‘‘I don’t know why, I can’tdo otherwise’’. Although she had aslowing of her mental functions, herlanguage was clear and the patient didnot present any gross deficits in hercognitive abilities (a complete neurop-sychological evaluation was impossiblebecause of bilateral ptosis and severeoculomotor palsy).Brain imaging (magnetic resonanceimaging) showed bilateral thalamicinfarction (fig 1A). No embolic source was found on cardiac, cervical andtranscranial ultrasound. DISCUSSION We report the case of a patient whopresented with disturbing sexual beha- viour following coma and oculomotorpalsy, related to an embolism in para-median arteries of the thalamus.There are four major thalamic vascularterritories, each with a predilection forsupplying particular groups of nuclei: thetuberothalamic, the inferolateral, theposterior choroidal and the paramedian vessels. The paramedian arteries arisefrom a short portion of the posteriorcerebral arteries situated between thebasilar bifurcation and the junction withthe posterior communicating artery (alsocalled the P1 section). To a variableextent, they supply the thalamus whichis principally constituted by the dorso-and posteromedial nuclei, the internalmedullary lamina, and the intralaminarnuclei. In some cases, a single parame-dian artery supplies both sides. Whenthis anatomical variation is present,stroke results in a bilateral paramedianthalamic infarct (fig 1A), the classicalfeatures of which include deep coma,abnormal eye movements, and cognitiveand behavioural impairment. 1 Comaresults from the discontinuance of ascending fibres srcinating in the reti-cular formation which is involved inarousal mechanisms. Abnormal eyemovements result from infarction in themidbrain nucleus which is usually asso-ciated (fig 1B). When the decrease in thelevel of consciousness resolves, cognitiveand behavioural changes become moreapparent: disorientation, Korsakoff-likeamnesia, apathy, loss of psychic self-activation, dysinhibited behaviour, andaggressiveness. Amnesia results frominjury to the Papez circuit, whichincludes the mamillothalamic tract andthe anterior nucleus of the thalamus.Behavioural disturbances are explainedby discontinuance of the thalamocorticalfibres, especially when the dorsomediannucleus, which massively projects ontothe frontal cortex, is involved. 2 Disorders of sexual behaviour afterinjury to the brain are infrequent andusually occur following lesions in the Figure 1  Magnetic resonance imaging-T2axial slice through the thalami (A) and themidbrain (B) and a diffusion-weighted MRI(not shown) showing a hypersignalcompatible with a recent infarct in theterritory of the paramedian arteries.600  Emergency casebook   www.emjonline.com  amygdala, the hypothalamus or thetemporal or frontal circuits. They haverarely been described after bilateral tha-lamic infarction and usually occur inhypersexuality. 3 Masturbating stereo-types have occasionally been reportedand are associated with frontal hypoper-fusion. 4 This case report involving the preva-lence of behavioural disorders under-scores the possible heterogeneity whichcan be seen in this syndrome. Sincepatients often initially present with theabrupt onset of coma, bilateral thalamicinfarcts are usually referred to the inten-sive care unit and early diagnosis isdifficult. Recognising these behaviouraldisorders as symptoms of focal braininfarction is important in terms of thediagnostic management and prognosis.  ACKNOWLEDGEMENTS Donald Schwartz revised the English. Emerg Med J   2007; 24 :600–601.doi: 10.1136/emj.2007.047662  Authors’ affiliations....................... Karl Mondon, Isabelle Bonnaud, Se´verineDebiais, Paul Brunault, Denis Saudeau,Bertrand de Toffol, Alain Autret,  Service deNeurologie et Universite´ Franc¸ois Rabelais,CHRU de Tours, Tours, FranceCorrespondence to: Dr K Mondon, Service deNeurologie, Hoˆpital Bretonneau, 37044 ToursCedex, France; karl.mondon@med.univ-tours.fr  Accepted 21 April 2007 Competing interests: None declared. REFERENCES 1  Schmahmann JD . Vascular syndromes of thethalamus.  Stroke   2003; 34 :2264–78.2  Carrera E , Bogousslavsky J. The thalamus andbehavior: effects of anatomically distinct strokes. Neurology   2006; 66 :1817–23.3  Spinella M . Hypersexuality and dysexecutivesyndrome after thalamic infarct.  Int J Neurosci  2004; 114 :1581–90.4  Mutarelli EG , Omuro AM, Adoni T. Hypersexuality following bilateral thalamic infarction: case report.  Arq Neuropsiquiatr   2006; 64 :146–8. Traumatic diaphragmatic rupture: adiagnostic challenge in the emergency department   Wei-Jing Lee, Ying-Sheng Lee  A  24-year-old man presented to theemergency department after fall-ing down from the fourth floorof a building on a construction site.Upon arrival he was alert, but dys-pnoeic. The breath sounds over the leftside of the chest were decreased. A chest radiograph was taken andrevealed elevation of the left side of the hemidiaphragm (fig 1). Computedtomography of the chest was arrangedto determine the severity of the lunginjury (fig 2).The incidence rates of traumaticdiaphragm rupture is between 0.8–1.6% of patients admitted because of blunt trauma. 1 Left-sided rupture ismore common than right-sided rupture(68.5% vs 24.2%). 2 Hepatic protectionof the right side, increased strength of the right hemidiaphragm, and weak-ness of the left hemidiaphragm atpoints of embryonic fusion all contri-bute to the predominance of left-sideddiaphragmatic rupture. 3  A delayeddiagnosis of diaphragm rupture andits associated injuries to the chest wall,abdominal cavity, and pelvic cavity canresult in life-threatening sequelae.Surgery should be performed as soonas the clinical diagnosis is made, eitherthrough the transabdominal approachor via thoracotomy. Emerg Med J   2007; 24 :601.doi: 10.1136/emj.2006.040451  Authors’ affiliations.......................  W-J Lee, Y-S Lee,  Department of Emergency Medicine, Chi-Mei Medical Center, Yung-KangCity, Tainan, TaiwanCorrespondence to: Dr Yiing-Sheng Lee,Department of Emergency Medicine, Chi-Mei,Medical Center, 901 Chung-Hwa Road, Yung-Kang City, Tainan 710, Taiwan; saab931103@ yahoo.com.tw  Accepted 24 July 2006Competing interests: None declared. REFERENCES 1  Ward RE , Flynn TC, Clark WP. Diaphragmaticdisruption due to blunt abdominal trauma.  J Trauma  1981; 21 :35–8.2  Shah R , Sabanathan S, Mearns AJ,  et al.  Traumaticrupture of diaphragm.  Ann Thorac Surg  1995; 60 :1444–9.3  Mansour KA  . Trauma to the diaphragm.  Chest Surg Clin N Am  1997; 7  :373–83. Figure 1  Chest radiograph showing an arch-like curvilinear density indicating elevation of theleft hemidiaphragm. Figure 2  CT scan showing herniation of intra-abdominal organs into the left thoracic cage. Images in emergency medicineEmergency casebook   601 www.emjonline.com
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