Adult Onset Simple Phonic Tic After Caudate Stroke

ADULT ONSET PHONIC TIC AFTER CAUDATE STROKE. 765

Adult Onset Simple Phonic Tic previous lacunar infarct in the right lenticular nucleus. The magnetic resonance imaging (MRI), which included After Caudate Stroke a diffusion sequence, performed in the first week after Meritxell Gomis, MD,* Victor Puente, MD, stroke onset showed an acute lacunar infarct located in Claustre Pont-Sunyer, MD, Carlos Oliveras, MD, and the tail of the left caudate nucleus (see Fig. 1). Jaune Roquer MD, PhD During hospitalization the patient improved, and after Servei de Neurologia, Hospital del Mar, Passeig Marı´tim seven days from admission recovered. 25-29, Barcelona, Spain Within three weeks after the stroke he noticed the onset of involuntary “a” sound with no premonitory symptoms. He observed that stress exacerbated the phonic tic. He was able to suppress it voluntarily for only very short periods of time and then experienced an urge. Because of the interfer- Abstract: We describe a case of adult onset simple phonic tic after subcortical stroke involving left caudate nucleus. ence of the tic, the prosody of the patient speech was not In the acute phase of stroke the patient presented a mild normal. The patient did not present the phonic tic during right clumsiness with complete recovery one week after sleep. No motor tic was observed and he denied exposure to onset. Within 3 weeks after stroke the patient noticed the any medication or illicit drugs. Personal and family history gradual onset of involuntary simple phonic tic consisting of an “a” sound which persists. The patient did not for tics or behavioral disorders was negative. present motor tics or the typical Tourette syndrome Except for the phonic tic, the results of the patient’s co-morbidities, such as attention deficit or obsessive- physical and neurological examinations were normal, as compulsive disorder. © 2008 Movement Disorder Society were the neuropsychological tests. The MRI showed an Key words: phonic tic; subcortical stroke; Tourette syn- acute ischemic lesion involving the left caudate nucleus drome; caudate nucleus. and some previous lacunar strokes. Functional imaging using photon emission computerized tomography Motor and phonic tics are most frequently due to (SPECT) highlighted abnormal patterns of blood flow Tourette Syndrome (TS). There are, however, many and metabolism in the left basal ganglia, and in the motor other causes of tics, such as various acquired and con- cortex of the left frontal lobe. genital neurological and neuropsyquiatric disorders, or The phonic tic only partially responded to pimozide exposure to a range of drugs.1 Acute brain injury such as treatment, which the patient discontinued due to severe stroke, central trauma, and peripheral injury has been somnolence. associated with a variety of movement disorders, most DISCUSSION 2,3 frequently dystonia and tremor. Although subcortical Tics are abrupt, repetitive movements (motor tics), or 4 stroke has been described as a cause of TS, stroke as a sounds (phonic tics), that are commonly preceded by a cause of simple phonic tic has not been reported. premonitory sensation of an extreme tension discomfort We report an adult patient who presented a simple motor or other sensory phenomena.5 phonic tic three weeks after acute left caudate stroke. Motor and phonic tics are usually seen in children, most CASE REPORT frequently due to TS, but there are many other causes of 1 A 71-year-old man, right-handed, ex-smoker, and with tics. In a study evaluating tics and co-existing disorders, ϳ hypertension as a vascular risk factor, was admitted to 9% of the sample had tics associated with an effect on the the hospital due to suddenly suffering a slight clumsiness basal ganglia; and stroke represented 1.2% of these. 6 on his right side. The neurological exam showed a mild In one of the few large prospective studies evaluating right clumsiness and a gait disturbance. On admission a the involuntary abnormal movements following a stroke, CT scan did not show anomalies with the exception of a it was observed that the frequency of these movements was ϳ3.7%. Chorea was the commonest movement al- though dystonia, tremor, and parkinsonism were also This article includes supplementary video clips, available online at observed, but not tics. http://www.interscience.wiley.com/jpages/0885-3185/suppmat Although the specific etiology and pathogenesis of tics *Correspondence to: Dr. M. Gomis, Servei de Neurologı´a, Hospital del Mar, Passeig Marı´tim 25-29, 08003, Barcelona, Spain. cannot always be determined, in many cases of tics not E-mail: [email protected] related to TS a clear anatomical-clinical relationship can be Received 15 May 2007; Revised 21 December 2007; Accepted 24 established. The association of tics with well-documented December 2007 Published online 8 February 2008 in Wiley InterScience (www. lesions involving the basal ganglia suggests that these sub- interscience.wiley.com). DOI: 10.1002/mds.21955 cortical structures play an important role in the genesis of

Movement Disorders, Vol. 23, No. 5, 2008 766 M. GOMIS ET AL.

dence linking sound production and excitability changes in the motor cortex is of interest.13 In our case, brain MRI showed an acute lesion in the left basal ganglia specifically in the tail of the caudate nucleus suggesting that the tic was secondary to this lacunar stroke. The SPECT, however, showed abnormal patterns of blood flow, not only in the left basal ganglia but also in the motor area of the left frontal lobe. It is possible, therefore, that disinhibition of the cortico-stri- atal-thalamic-cortical circuitry plays a role in its patho- genesis.12,14 Legends to the Video The video shows the simple phonic tic of the patient. The neurological examination, with the exception of the tic was normal. During the video we asked to suppress the tic, and after this the patient had an urge.

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