Acute pseudobulbar or suprabulbar palsy

A Rare Case of a Good Neurological Outcome following Traumatic Foix-Chavany-Marie Syndrome

Traumatic brain injury (TBI) can have profound acute and chronic effects, leading to permanent disabilities and diminished quality of life. Pseudobulbar palsy and its infrequent subtype, Foix-Chavany-Marie Syndrome (FCMS), represent rare complications of TBI, manifesting as deficits in craniofacial motor function and automatic-voluntary dissociation. We present a case of a 58-year-old male who developed FCMS following severe TBI from a cycling accident. Initial imaging revealed extensive brain injury with subsequent development of FCMS characterised by bilateral cranial nerve dysfunction, notably facio-pharyngo-glosso-masticatory diplegia with preserved automatic motor function. This case contributes to the limited literature on traumatic FCMS, highlighting its distinct clinical features and potential for favourable outcomes compared to nontraumatic cases. Early recognition and comprehensive management, including supportive therapy and addressing underlying conditions, are paramount for optimising patient outcomes.

Isolated acute pseudobulbar palsy with infarction of artery of percheron: case report and literature review

Introduction

Pseudobulbar palsy (PBP) is characterized by supranuclear lesions in the corticobulbar pathway. Neoplasia, inflammatory, demyelinating, and stroke are possible etiologies of this disorder.

Case report

We report an elderly female who presented with dysarthria. She was dysarthric with a hypernasal voice, no apraxia or aphasia was observed. Tongue movements were slow with limited amplitude. Her soft palate dropped bilaterally; gag reflex was present. Also, she reported swallowing difficulty and choking with her saliva. Bilateral vertical and horizontal gaze were intact to either voluntary or oculocephalic movements. A cranial CT scan was suggestive of artery of Percheron (AOP) infarction. Brain magnetic resonance imaging showed hypersignal on diffusion-weighted and T2-weighted images and hyposignal on apparent diffusion coefficient in both thalami. CT angiography scan revealed an AOP originating from the left posterior cerebral artery. The swallowing study with a videofluoroscopic demonstrated oral and pharyngeal phases with severe dysfunction.

Conclusion

To the authors' knowledge, there are two cases of individuals with artery of Percheron infarction who developed PBP associated with other clinical syndromes. Still, isolated PBP following infarction of Percheron's artery was not reported. We hypothesized that the PBP may have occurred because of the existence of vascular territory variations in the perforating arteries that arise from the AOP.

Dysphagia in supratentorial recent small subcortical infarcts results from bilateral pyramidal tract damage

Background

Dysphagia occurs in up to 20% of patients with a recent small subcortical infarct, even when excluding brainstem infarcts.

Aim

To examine the impact of lesion topography and concomitant cerebrovascular lesions on the occurrence of dysphagia in patients with a single supratentorial recent small subcortical infarct.

Methods

We retrospectively identified all inpatients with magnetic resonance imaging-confirmed supratentorial recent small subcortical infarcts over a five-year period. Dysphagia was determined by speech-language therapists. Recent small subcortical infarcts were compiled into a standard brain model and compared using lesion probability maps. Furthermore, magnetic resonance imaging scans were reviewed for the combination of both acute and old cerebrovascular lesions.

Results

A total of 243 patients with a recent small subcortical infarct were identified (mean age 67.9 ± 12.2 years). Of those, 29 had mild and 18 moderate-to-severe dysphagia. Lesion probability maps suggested no recent small subcortical infarct location favoring the occurrence of moderate-to-severe dysphagia. However, patients with moderate-to-severe dysphagia more frequently showed combined damage to both pyramidal tracts by the recent small subcortical infarct and a contralateral old lesion (lacune: 77.8% vs. 19.9%, p < 0.001; lacune or confluent white matter hyperintensities: 100% vs. 57.7%, p < 0.001) than patients without swallowing dysfunction. Comparable results were obtained when analyzing patients with any degree of dysphagia.

Conclusions

Preexisting contralateral vascular pyramidal tract lesions are closely related to the occurrence of moderate-to-severe dysphagia in patients with supratentorial recent small subcortical infarcts.

Acute Bilateral Opercular Strokes Causing Loss of Emotional Facial Movements

The classic anterior opercular syndrome of Foix-Chavany-Marie presents with loss of voluntary facial, pharyngeal, lingual, and mastication movements, with preservation of emotional and automatic movements. Most commonly, sequential strokes affecting bilateral opercula cause this syndrome. The inverse clinical presentation, with selective loss of emotional facial movements, has only rarely been reported, and is less well-localized.

Case report:

We report a case of selective loss of emotional facial movements which resulted from bilateral acute infarcts. No etiology was discovered, and the syndrome was reversible.

Discussion:

The available literature, and findings in this case, suggest that voluntary and automatic facial movements have distinct pathways, and damage to the insula bilaterally may lead to the selective loss of emotional facial movements. The clinical presentation of this inverse automatic/voluntary dissocation needs to be recognized as a rare syndrome with bilateral localization, so that patients at higher risk of further stroke can quickly be identified.

Severe brain atrophy in the elderly as a risk factor for lower respiratory tract infection

BACKGROUND

The purpose of this study is to determine whether elderly subjects with severe brain atrophy, which is associated with neurodegeneration and difficulty swallowing (dysphagia), are more susceptible to lower respiratory tract infections (LRTI), including pneumonia.

METHODS

The severity of brain atrophy was assessed by computed tomography in 51 nursing home residents aged 60-96 years. The incidence of LRTI, defined by body temperature ≥ 38.0°C, presence of two or more respiratory symptoms, and use of antibiotics, was determined over 4 years. The incidence of LRTI was compared according to the severity and type of brain atrophy.

RESULTS

The incidence rate ratio of LRTI was significantly higher (odds ratio 4.60, 95% confidence interval 1.18-17.93, fully adjusted P = 0.028) and the time to the first episode of LRTI was significantly shorter (log-rank test, P = 0.019) in subjects with severe brain atrophy in any lobe. Frontal and parietal lobe atrophy was associated with a significantly increased risk of LRTI, while temporal lobe atrophy, ventricular dilatation, and diffuse white matter lesions did not influence the risk of LRTI.

CONCLUSION

Elderly subjects with severe brain atrophy are more susceptible to LRTI, possibly as a result of neurodegeneration causing dysphagia and silent aspiration. Assessing the severity of brain atrophy might be useful to identify subjects at increased risk of respiratory infections in a prospective manner.

Progressive anterior operculum syndrome due to FTLD-TDP: a clinico-pathological investigation

Pathological investigation of progressive anterior operculum syndrome has rarely been reported. We describe clinico-pathological findings in a patient with progressive anterior operculum syndrome. A 74-year-old right-handed man had noticed speech and swallowing difficulties 1 year previously. Neurological examinations showed no abnormality other than a slight limitation of upward gaze and slow tongue movement without fibrillation. We investigated the patient using neuroimaging and neuropsychological examinations and observed him for 2 years until his death, at which point we obtained pathological findings. The patient's facial and masseteric muscles seemed hypotonic with drooling, but he could laugh and yawn normally, showing automatic voluntary dissociation. Palatal and pharyngeal reflexes were normal. Magnetic resonance imaging showed cortical atrophy in the temporal lobes bilaterally. (123)IMP single photon emission computed tomography and positron emission tomography showed decreased blood flow and activity in the frontotemporal lobes, predominantly on the left side. Neuropsychological examinations showed no aphasia, dementia or other neuropsychological abnormality. Intubation fiberscopy, laryngoscopy and video fluorography showed no abnormality. After 6 months his anarthria and dysphagia became aggravated. He died of aspiration pneumonia 2 years after onset. Postmortem examination revealed neuronal degeneration with TDP-43-positive inclusions in the frontal, temporal and insular cortices, consistent with frontotemporal lobar degeneration with TDP inclusions (FTLD-TDP). However, neuronal loss with gliosis was more prominent in the inferior part of the motor cortices, bilaterally. Progressive anterior operculum syndrome could be classified as a variant of FTLD-TDP.

Involuntary emotional expression disorder: definition, diagnosis, and measurement scales

Involuntary emotional expression disorder (IEED) is a syndrome in which emotional or affective motor control becomes dysregulated as a result of brain damage from neurological disease or as a result of brain injury. A debilitating disorder with persistent symptoms, IEED has a significant impact upon the lives of patients and caregivers, but is often overlooked or misdiagnosed. IEED is a clinically well-defined disorder, and specific criteria may be used when making a diagnosis. It must be distinguished from depression or other psychological and neurological conditions. Several assessment scales have been validated for use in IEED, in order to evaluate the baseline severity and to track the course of the disorder and response to treatment.

Acute pseudobulbar palsy as the initial presentation of intravascular lymphomatosis

We describe the case of a 76-year-old male patient who developed acute manifestations of pseudobulbar palsy without a history of stroke or vascular risk factors as the first manifestation of intravascular lymphomatosis. Neurological symptoms of acute pseudobulbar palsy appeared on the second postoperative day after transurethral prostatectomy for the treatment of prostatic hypertrophy. Intravascular lymphomatosis was diagnosed from microscopic findings and immunohistochemical staining of the surgical specimen. Chemotherapy was started, but the patient died due to sepsis secondary to bone marrow aplasia. Intravascular lymphomatosis should be considered a rare potential cause of acute pseudobulbar palsy.

Transient Foix-Chavany-Marie syndrome after surgical resection of a right insulo-opercular low-grade glioma: case report

OBJECTIVE AND IMPORTANCE

We describe an atypical case of transient Foix-Chavany-Marie syndrome, or faciopharyngoglossomasticatory diplegia with automatic voluntary dissociation, occurring after surgical resection of a right insulo-opercular glioma.

CLINICAL PRESENTATION

A 26-year-old right-handed man experienced partial seizures that were poorly controlled by antiepileptic drugs during a 2-year period as a result of a right insulo-opercular low-grade glioma, leading to the proposal of surgical resection. In addition, 1 year before the operation, the patient experienced a severe brain injury that resulted in a coma. A computed tomographic scan revealed left opercular contusion. The patient recovered completely within 6 months.

INTERVENTION

Intraoperative corticosubcortical electrical functional mapping was performed along the resection, allowing the identification and preservation of the facial and upper limb motor structures. A subtotal removal of the glioma was achieved. The patient had postoperative anarthria, with loss of voluntary muscular functions of the face and tongue, and he had trouble chewing and swallowing. All of these symptoms resolved within 3 months.

CONCLUSION

These findings provide insight into the use of surgery to treat a right insulo-opercular tumor. First, surgeons must be particularly cautious in cases with a potential contralateral lesion (e.g., history of head injury), even if such a lesion is not visible on magnetic resonance imaging scans; preoperative metabolic imaging and electrophysiological investigations should be considered before an operative decision is made. Second, surgeons must perform intraoperative functional mapping to identify and to attempt to preserve the corticosubcortical facial motor structures. A procedure performed while the patient is awake should be discussed to detect the structures involved in chewing and swallowing in cases of suspected bilateral lesions. Third, the patient must be informed of this particular risk before surgery is performed.

Neural control of tongue movement with respect to respiration and swallowing

The tongue must move with remarkable speed and precision between multiple orofacial motor behaviors that are executed virtually simultaneously. Our present understanding of these highly integrated relationships has been limited by their complexity. Recent research indicates that the tongue s contribution to complex orofacial movements is much greater than previously thought. The purpose of this paper is to review the neural control of tongue movement and relate it to complex orofacial behaviors. Particular attention will be given to the interaction of tongue movement with respiration and swallowing, because the morbidity and mortality associated with these relationships make this a primary focus of many current investigations. This review will begin with a discussion of peripheral tongue muscle and nerve physiology that will include new data on tongue contractile properties. Other relevant peripheral oral cavity and oropharyngeal neurophysiology will also be discussed. Much of the review will focus on brainstem control of tongue movement and modulation by neurons that control swallowing and respiration, because it is in the brainstem that orofacial motor behaviors sort themselves out from their common peripheral structures. There is abundant evidence indicating that the neural control of protrusive tongue movement by motoneurons in the ventral hypoglossal nucleus is modulated by respiratory neurons that control inspiratory drive. Yet, little is known of hypoglossal motoneuron modulation by neurons controlling swallowing or other complex movements. There is evidence, however, suggesting that functional segregation of respiration and swallowing within the brainstem is reflected in somatotopy within the hypoglossal nucleus. Also, subtle changes in the neural control of tongue movement may signal the transition between respiration and swallowing. The final section of this review will focus on the cortical integration of tongue movement with complex orofacial movements. This section will conclude with a discussion of the functional and clinical significance of cortical control with respect to recent advances in our understanding of the peripheral and brainstem physiology of tongue movement.

Cerebral blood flow in pure dysarthria: role of frontal cortical hypoperfusion

BACKGROUND AND PURPOSE

Isolated dysarthria, termed pure dysarthria, develops rarely after stroke, and its pathophysiology remains unclear. To clarify the underlying mechanism of pure dysarthria, we investigated lesion sites and cerebral blood flow in patients with pure dysarthria.

METHODS

We examined 12 patients with pure dysarthria who underwent MRI and cerebral blood flow study. To visualize cortical blood flow, a three-dimensional display was generated from single-photon emission computed tomography (SPECT). Regional cerebral blood flow of the patients was semiquantitatively measured with SPECT and N-isopropyl-p[123I]iodoamphetamine as a tracer and compared with that of 11 control subjects.

RESULTS

On MRI, multiple lacunar infarctions were noted bilaterally in 11 patients, all of whom had lesions involving the internal capsule or corona radiata. The other patient had a unilateral internal capsule-corona radiata infarction. Three-dimensional display showed frontal cortical hypoperfusion in 8 patients. Since interhemispheric differences of blood flow were not significant in any region of the 12 patients, the mean of left and right cortical blood flow was analyzed. Compared with the control subjects, cortical perfusion was significantly reduced in the patients' frontal regions, sparing the sensorimotor, temporal, and parietal cortices and the cerebellum. Reductions of perfusion were rather pronounced in the anterior opercular, medial prefrontal and premotor, and anterior cingulate regions.

CONCLUSIONS

Pure dysarthria results mainly from multiple lacunar infarctions, which induce frontal cortical hypoperfusion, probably due to interruption of corticosubcortical networks. We conclude that frontal cortical hypoperfusion, particularly in the anterior opercular and medial frontal regions, plays an important role in the development of pure dysarthria.

Pure congenital Foix-Chavany-Marie syndrome

Foix-Chavany-Marie syndrome (FCMS) is characterized by facio-linguo-masticatory diplegia in the absence of limb weakness. The most common cause is a cortical lesion resulting from a stroke but a congenital form has been reported. We present the case of a 53-year-old man who was admitted to hospital with worsening dysphagia which was know to have been present together with anarthria and facial palsy, since birth. He demonstrated features of FCMS with pseudobulbar palsy and unaffected reflexes and automatic responses. Cranial CT and MRI scans showed bilateral opercular lesions of CSF intensity in continuity with the lateral ventricles. We conclude that this case of static FCMS for over 50 years may represent a 'pure' form of congenital FCMS with motor symptomatology and unaccompanied by mental retardation or epilepsy.

Apneustic breathing provoked by limbic influences

We describe a 64-year-old man with cerebrovascular disease who had an acute stroke characterised by pseudobulbar palsy, facial weakness, and pyramidal signs. He developed frequent emotional outbursts followed by periods of apneusis. Between these episodes he breathed with a regular and unvarying rate and tidal volume. Autopsy showed extensive cortical, subcortical and pontine infarction. The respiratory pattern indicated a dissociation between voluntary and automatic pathways. The descending limbic pathways were preserved but an abnormal pattern of automatic breathing (ie, apneusis) occurred because of the presence of bilateral pontine infarction.

Pathological laughter and crying in patients with closed traumatic brain injury

We report on the clinical and radiological features in 16 adult patients who suffered a traumatic brain injury and subsequently developed pathological laughter and crying. Patients with pathological laughter and crying were identified from among 301 consecutive brain-injured admissions to a trauma centre and subsequently to a rehabilitation facility. Patients displaying pathological laughter and crying had a greater severity of injury than patients without the syndrome; they also had other associated neurological features compatible with pseudobulbar palsy. Pathological laughter alone, or combined with crying, was more frequent than crying alone. An attempt to correlate clinical features with focal lesions on neuroimaging studies yielded inconsistent results. The theoretical anatomical substrate for pathological laughter and crying in patients with traumatic brain injury is discussed.

Bilateral perisylvian syndrome not related to malformations: report of two cases

In this case report we present the neuroimaging findings and clinical features of two patients with a bilateral perisylvian syndrome not related to malformations, but probably to ischemic etiology. Evaluations including history, general and neurologic examinations, electroencephalograms, and imaging data were reviewed as recent literature about the subject.

Acquired bilateral opercular lesions or Foix-Chavany-Marie syndrome and eating epilepsy

Images

Incontinência do choro e infarto protuberancial unilateral

O presente estudo trata do caso de um paciente que apresentou incontinência do choro e hemiplegia direita por infarto ventroprotuberancial paramediano detectado pela RNM. O caráter circunscrito da lesão foi endossado pela normalidade dos potenciais evocados sômato-sensitivos e auditivos de curta-latência. Os episódios de choro desapareceram poucos dias depois do início do tratamento com doses baixas de imipramina. Discutimos o choro e riso patológicos como forma de incontinência da mímica resultante de desconexão límbico-motora, enfatizando a impropriedade de incluí-los na síndrome pseudobulbar, uma vez que dependem de correlatos anatômicos e funcionais distintos.

Pseudobulbar palsy associated with trismus

A 60 year old patient presented with an acute pseudobulbar palsy associated with trismus. A computed tomography scan revealed low attenuation areas consistent with infarction affecting the genu of the internal capsules bilaterally. Trismus has not previously been described as the presenting feature of a pseudobulbar palsy.

Pure dysarthria, isolated facial paresis, or dysarthria-facial paresis syndrome

BACKGROUND AND PURPOSE

Pure dysarthria, isolated supranuclear facial paresis, and their combination without somatic motor dysfunction are rarely encountered clinical syndromes and have not yet been clearly characterized.

METHODS

Thirteen patients (9 men, 4 women; aged 33 to 72 [mean, 56] years) with unilateral strokes who developed dysarthria with or without facial paresis but without somatic motor dysfunction were reviewed in addition to case reports from previous literature.

RESULTS

Computed tomographic scan and/or magnetic resonance imaging showed infarcts on the corona radiata in 4 patients, basal ganglia abutting the internal capsule in 3, basal ganglia-corona radiata in 1, pontine base in 3, and cortical-subcortical bulbar motor area in 2. The dysarthria and facial paresis were usually mild and transient, and either one was likely to be unnoticed.

CONCLUSIONS

It is suggested that pure dysarthria or isolated facial paresis syndrome be considered as an extreme continuum of dysarthria-facial paresis syndrome, which is likely to be a variant of dysarthria-clumsy hand syndrome.

Paraballism associated with anterior opercular syndrome: a case report

We describe the combination of acute bilateral ballism and anterior opercular syndrome in a 75-year-old female hypertensive patient with bilateral multiple small infarcts involving the basal ganglia, the subcortical white matter and the area of the subthalamic nucleus, detected by CT scan and MRI. These clinical manifestations were accompanied by apathy, somnolence and cognitive changes usually observed in cortical involvement. Pathogenetic mechanisms for this unusual clinical picture are discussed on the basis of CT, MRI, and SPECT findings.

Reversible bilateral opercular syndrome secondary to AIDS-associated cerebral toxoplasmosis

A case of reversible anterior bilateral opercular syndrome (Foix-Chavany-Marie syndrome) secondary to cerebral toxoplasma abscesses is described in a patient with AIDS. The symptoms regressed following antitoxoplasma and antiedema drug therapy. Although this is the first reported AIDS-related case, the syndrome is likely to recur in AIDS sufferers in whom multifocal cerebral lesions are common.

Anterior opercular cortex lesions cause dissociated lower cranial nerve palsies and anarthria but no aphasia: Foix-Chavany-Marie syndrome and "automatic voluntary dissociation" revisited

Anarthria and bilateral central facio-linguovelo-pharyngeo-masticatory paralysis with "automatic voluntary dissociation" are the clinical hallmarks of Foix-Chavany-Marie syndrome (FCMS), the corticosubcortial type of suprabulbar palsy. A literature review of 62 FCMS reports allowed the differentiation of five clinical types of FCMS: (a) the classical and most common form associated with cerebrovascular disease, (b) a subacute form caused by central nervous system infections, (c) a developmental form probably most often related to neuronal migration disorders, (d) a reversible form in children with epilepsy, and (e) a rare type associated with neurodegenerative disorders. Bilateral opercular lesions were confirmed in 31 of 41 patients who had CT or MRI performed, and by necropsy in 7 of 10 patients. FCMS could be attributed to unilateral lesions in 2 patients. The typical presentation and differential diagnosis of FCMS provide important clues to lesion localization in clinical neurology. FCMS is a paretic and not an apraxic disorder and is not characterized by language disturbances. Its clinical features prove divergent corticobulbar pathways for voluntary and automatic motor control of craniofacial muscles. Precise clinico-neuroradiological correlations should facilitate the identification of the structural substrate of "automatic voluntary dissociation" in FCMS.