Akinetic mutism caused by bilateral infiltration of the fornix in a patient with astrocytoma.
In a 59-year-old female patient, a World Health Organization (WHO) grade II astrocytoma had been diagnosed 16 years ago, which finally progressed into WHO grade III. Several right frontal neurosurgical resections, local radiation and a local radioimplant had been applied. Despite this long record, she was reported alert with a Karnofsky index of 90% until admission. Within a few weeks she rapidly developed akinetic mutism. Upon admission, computed tomography (CT) scan showed a large cystic right frontal defect and a suggested small tumor recurrence. White matter of the frontal lobe appeared to be translucent and compatible with previous radiation. The severe mental changes were initially attributed to a delayed radiation encephalopathy. Neuropathologically, the white matter of the frontal lobe showed mild elevated cell density consistent with gliosis; however, a tumor recurrence invading the tip of the corpus callosum and invading the entire length both fornices appeared. From the neuropathological findings of massive local tumor recurrence in both fornices, together with the acute clinical onset, it seems unlikely that the sequel of radiotherapy caused akinetic mutism, but the symmetric and severe involvement of the limbic system. We conclude that the rapid progression from a state of alertness to a full clinical picture of akinetic mutism was because of infiltration of both fornices.
Oberndorfer
S
S
Department of Neurology, Ludwig Boltzmann Institute for Neurooncology Vienna/Linz, Kaiser Franz Josef Hospital, Austria. stefan.oberndorfer@kfj.magwien.gv.at
Urbanits
S
S
Lahrmann
H
H
Kirschner
H
H
Kumpan
W
W
Grisold
W
W
D000405:Akinetic Mutism / Q000209:etiology* / Q000473:pathology; D001254:Astrocytoma / Q000150:complications* / Q000473:pathology; D001932:Brain Neoplasms / Q000150:complications* / Q000473:pathology; D017809:Fatal Outcome; D005260:Female; D020712:Fornix, Brain / Q000473:pathology*; D006801:Humans; D008875:Middle Aged