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Akinetic Mutism Without a Structural Prefrontal Lesion

Demirtas-Tatlidede, Asli MD; Bahar, Sara Z. MD; Gurvit, Hakan MD

Cognitive and Behavioral Neurology: June 2013 - Volume 26 - Issue 2 - p 59–62
doi: 10.1097/WNN.0b013e31829bd4f5
Images in Clinical Cognitive Neuroscience

Akinetic mutism is characterized by profound apathy and a lack of verbal and motor output for action, despite preserved alertness. The condition usually follows bilateral damage to the medial frontal subcortical circuits. We report a 59-year-old right-handed woman who was admitted to the neurology ward with sudden-onset akinetic mutism. Her medical history included an ischemic stroke 3 years earlier, with residual anomia and mild agraphia but no motor dysfunction. On this admission, a cranial computed tomography scan disclosed an acute left superior cerebellar infarction embracing the vermis, and a prior left inferior parietal infarct. Electroencephalogram showed bilateral frontal delta-wave activity. Four weeks later, we performed a technetium-99m hexamethylpropyleneamine oxime single-photon emission computed tomography (99mTc-HMPAO SPECT) scan to study the patient’s frontal lobe function. The SPECT scan revealed the causative bifrontal hypoperfusion, more prominent on the right, while the structurally evident cerebellar infarction was predictably masked by subacute hyperperfusion phenomenon. Contralateral frontal diaschisis is an established sequela of cerebellar infarction. Because this patient also had lesions in the left parietal region, her left prefrontal area was critically deprived of its major reciprocally connected cortical counterparts (right prefrontal and left parietal), and also became dysfunctional. Her resulting bilateral frontal dysfunction is a common cause of akinetic mutism.

Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

The authors declare no conflicts of interest.

Reprints: Asli Demirtas-Tatlidede, MD, Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, Istanbul 34093, Turkey (e-mail:

Received September 17, 2012

Accepted December 4, 2012

© 2013 by Lippincott Williams & Wilkins.