Abstract
We reported a case of paramedian thalamic and midbrain infarcts. A 46-year-old man was admitted to our hospital because of disturbance of consciousness with urinary incontinence. He had aortic regurgitation and hypertension in his past histories. His family history was normal.
Physical examination on admission showed blood pressure 200/100 mmHg, pulse rate 22/minute, regular, diastolic murmur on the 4th left sternal border.
Neurological examination revealed as follows. His consciousness was somnolent. He could state his name, years and day by our asking. But the other words were too unclear to understand. He always closed his eyes. Downwards gaze was impossible. There was no nystagmus but doll's eye phenomenon could be elicited. Snout and jaw reflexes were exaggerated. There was hemiparesis bilaterally, which was prominent at left extremities. Muscle tone was more decreased at left extremities. Pathological reflexes were elicited bilaterally. There was hemisensory disturbance at left extremities. He showed urinary incontinence.
Laboratory data were normal. Lumber cerebrospinal fluid was normal. ECG showed no arrhythmia. Echocar-diogram showed aortic valve dilation but there was no echogenicity of thrombi. EEG showed diffuse slow alpha activities, alpha blocking and slightly mixed theta waves. Brain CT scan revealed butterfly-like low density areas in both thalami and well-defined low density area in the right mesencephalon. Vertebral artery angiogram showed the occlusion of the right basilar communicating artery.
We though this case a brainstem infarction and treated conservatively. He was improved gradually, however, showed fluctuation. Hypersomnia and abnormal behavior became disappeared. He could gait without help, get his speech back. But his intelligence remained to be decreased. Vertical gaze paralysis was remained. Involuntary movement appeared on the right hand lately.
We thought that this case was a paramedian thalamic and midbrain infarcts (Castaigne). Reffering some cases which similar clinical signs, we thought that the paramedian thalamic and midbrain infarcts were different from akinetic mutism and were special syndrome caused by the selective occlusion of the basilar communicating artery which has many variabilities of its perforating arteries.
