Right Anterior Thalamic Infarction Presenting Only with Cognitive Dysfunction

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1 Right Anterior Thalamic Infarction Presenting Only with Cognitive Dysfunction Sun Ah Park, Dong Chul Park*, Yeonwook Kang**, Kyoon Huh Department of Neurology, Ajou University School of Medicine, Yonsei University School of Medicine*, Samsung Medical Center** A 60 year-old right-handed man developed a sudden inability to find his way home from work. Neurologic examinations revealed no focal neurological deficit. Neuropsychological tests showed a memory deficit especially in the visuospatial domain along with visuospatial and frontal-executive dysfunction. A brain MRI revealed a small but discrete lesion in the right thalamus. The majority of the lesion was confined to the dorsomedial nucleus. These results suggest that a small unilateral thalamic infarction affecting the anterior area may be sufficient to produce strategic-infarct dementia without focal neurological deficit. J Korean Neurol Assoc 17(6):869~873, 1999 Key Words : Thalamus, Infarction, Memory, Dementia, MRI Sun Ah Park, M.D. Copyright 1999 by the Korean Neurological Association 869

2 Table 1. Neuropsychological test (Abnormal data underlied) Tests 4days 21days Attention Digit span (F/B) 6/3 5/3 Letter cancellation NL NL Language NL NL Praxis NL NL Finger naming NL NL Calculation NL NL Left-right orientation NL NL Memory Orientation to time 2(5) 1(5) to place 2(5) 2(5) 3 words registration 3(3) 3(3) 3 words recall 3(3) 3(3) Remote memory 1(5) 1(5) HVLT Free recall 20(36) 19(36) 20min recall 2(12) 2(12) recognition 6(12) 8(12) Rey figure test Immediate recall 5(36) 3(36) 20min recall 3(36) 2(36) Visuospatial function Rey figure copy 25(36) 24(36) Interlocking pentagon NL NL Hooper Not done 13(30) JOLO Not done 15(30) VSAT Not done very poor Frontal/Executive function Contrasting program NL NL Go-no-go test NL NL Fist-edge-palm NL NL Alternating S & T Deformed and NL Perseveration Luria loop Deformed and NL Perseveration Word fluency (A/M) 3/10 11/7 Abstract reasoning NL NL WCS Not done 2 categories Trail making test Not done A:1min06sec B: 2min26sec F/B: forward/ backward, NL: normal, Hooper: Hooper visual organization test, JOLO: Judgement of line orientation, VSAT: Visual search and attention test, 20min: 20 minutes delay, S & T: square and triangle, A/M: animal /market, WCS: Wisconsin card sorting ( ): The figure in it means full score. 870 J Korean Neurol Assoc / Volume 17 / November, 1999

3 Figure 1. Diffusion weighted image, axial (T2WI), and coronal (T1WI) MRIs. A discrete thalamic infarction was noted as high signal in axial scans of diffusion weighted (1a) and T2 weighted (1b) images, and low signal in T1 coronal image (1c). J Korean Neurol Assoc / Volume 17 / November,

4 Ant: anterior nucleus, VA: ventral anterior nucleus, VL: ventral lateral nucleus, DM: dorsomedial nucleus, CM: centromedial nucleus, P: pulvinar, MTTr: mammillothalamic tract, SMT: stria medullaris thalami Figure 2. Thalamic lesion (dotted area; fig. 2a and 2b) reconstructed on the axial and coronal plates redrawn and modified from Haines. 15.,,,,,,. 11. Woo J, Kay R, Yuen Y, Nicholls MG. Factors influencing long-term survival and disability among three-month stroke survivors. N e u r o e p i d e m i o l o g y 11: , Tatemichi TK, Paik M, Bagiella M, Desmond DW, Pirro M, Hanzawa LK. Dementia after stroke is a predictor of long-term survival. Stroke 25: Roman GC, Tatemichi TK, Erkinjuntti T, et al. Vascular dementia:diagnostic criteria for research studies: Report of the NINDS-AIREN international workshop. Neurology 43: , Bogousslavsky J, Regli F, Uske A. Thalamic infarct: Clinical syndromes, etiology, and prognosis. N e u r o l o g y 28 : ,1988. : 6. 2: , Lisovoski F, Koskas P, Dubard T, Dessarts I, Dehen H, Cambier J. Left tuberothalamic artery territory infarction: Neuropsychological and MRI features. Eur Neurol 33 : , Speedie LJ, Heilman KM. Anterograde memory deficits for visuospatial material after infarction of the right thalamus. Arch Neurol 40: , Graff-Radford NR, Eslinger PJ, Damasio AR, Yamada T. Nonhemorrhagic infarction of the thalamus: Behavioral, anatomic, and physiologic correlates. N e u r o l o g y 34 : 14-23, Bogousslavsky J, Regli F, Assal G. The syndrome of uni- lateral tuberothalamic artery territory infarction. S t r o k e 17: , Haines DE. Neuroanatomy: An atlas of structures, sec - tions and systems. 3rd ed. Baltimore-Munich: Urban & Schwarzenberg, von Cramon DY, Hebel N, Schuri U: A Contribution to the anatomical basis of thalamic amnesia. Brain 108: , Graff-Radford NR, Tranel D, van Hoesen GW, Brandt JP. Diencephalic amnesia. Brain 113:1-25, Parkin AJ, Rees JE, Hunkin NM, Rose PE. Impairment of memory following discrete thalamic infarction. Neuropsychologia 32 (1):39-51, Hennerici M, Halsband U, Kuwert T, Steinmetz H, Herzog H, Aulich A, Feinendegen LE. PET and neuropsychology 872 J Korean Neurol Assoc / Volume 17 / November, 1999

5 in thalamic infarction:evidence for associated cortical dysfunction. Psych Res 29: , Baron JC, D antona R, Pantano P, Serdaru M, Samson Y, Bousser MG. Effects of thalamic stroke on energy metabolism of the cerebral cortex. Brain 109: , Censori B, Manara O, Agostinis C, et al. Dementia after first stroke. Stroke 27: , Adams RD, Victor M, Ropper AH. Principles of Neurology. 6th ed. McGraw-Hill, 1997: J Korean Neurol Assoc / Volume 17 / November,