Session Time: 11:15am-12:45pm
Location: Research Hub - Kiosk 4
Disclosures: Emily Ryan-Michailidis, DO: Nothing to disclose
Case Description: A 22-year-old male developed a severe headache with vomiting followed by unresponsiveness with Glasgow Coma score of 4 on presentation. Head CT showed corpus callosal intraparenchymal hemorrhage, extensive intraventricular hemorrhage, hydrocephalus, subarachnoid hemorrhage bilaterally involving basal cisterns, and left midline shift. On CT angiography patient was found to have a ruptured right frontal arteriovenous malformation and underwent resection. After medical stabilization patient was transferred to acute inpatient rehabilitation with exam notable for dense left hemiplegia, right gaze preference with intermittent visual tracking, complete verbal mutism, and inconsistently followed commands. Based on exam and location of injury, specifically medial frontal lobes, anterior cingulate gyrus, and genu of corpus callosum, there was suspicion for akinetic mutism (AM). AM is a neurobehavioral condition marked by severe disturbances in motivational drive, and is considered a subset of the minimally conscious state. AM results from damage to dopaminergic pathways, which can be targeted using dopaminergic agents such as bromocriptine. This patient was already on low dose bromocriptine to address dysautonomia, however the dose was up titrated over 13 days to target AM.
Setting: Inpatient rehabilitation.
Patient: 22-year-old male with arteriovenous malformation rupture.
Assessment/Results: On day 4 of increased bromocriptine dose, the patient began speaking. Patient’s speech continued to improve, and he began to demonstrate improved motor initiation and consistently follow commands. Initial Orientation log score was 16 which rapidly improved to 28. Later bromocriptine was slowly tapered and discontinued, however patient maintained cognitive and motor gains.
Discussion: There is significant and sometimes dramatic benefit of bromocriptine in AM. When impairment is significant and risk factors few, higher doses should be considered.
Conclusion: AM is an uncommon condition that often goes unrecognized. It is important to recognize AM and distinguish it from other disorders of consciousness to ensure proper treatment, leading to gains in therapy and overall patient function.
Level of Evidence: Level V
To cite this abstract in AMA style:Ryan-Michailidis E, Horng J, Badri M, Ellis R, Nally E, Gurin L, Fusco H. Easy to Misdiagnose: An Obscure Case of Akinetic Mutism After Arteriovenous Malformation Rupture [abstract]. PM R. 2019; 11(S2)(suppl 2). https://pmrjabstracts.org/abstract/easy-to-misdiagnose-an-obscure-case-of-akinetic-mutism-after-arteriovenous-malformation-rupture/. Accessed February 27, 2024.
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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/easy-to-misdiagnose-an-obscure-case-of-akinetic-mutism-after-arteriovenous-malformation-rupture/