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Artery Infarctions1 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.1.84 on 1 January 1976. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry, 1976, 39, 84-89 Acute confusional states with right middle cerebral artery infarctions1 MAREK-MARSEL MESULAM, STEPHEN G. WAXMAN, NORMAN GESCHWIND, AND THOMAS D. SABIN From the Neurological Units, Beth Israel Hospital and Boston City Hospital; Departments of Neurology, Harvard Medical School and Tufts Medical School; and Aphasia Research Center, Department of Neurology, Boston University School of Medicine, Boston, Mass., U.S.A. SYNOPSIS Three patients presenting predominantly with acute confusional states (ACS) are shown to have infarctions in the distribution of the right middle cerebral artery. It is suggested that the main deficit in ACS is in the function of selective attention. On the basis of cortical connections of homc- logous areas in the monkey brain, it is argued that this deficit arises from lesions in convergence areas for association cortex. Protected by copyright. We would like to report three patients whose ACS cannot be specified, it has not been possible clinical presentation was dominated by acute to localize the responsible lesion. Our purpose confusional states (ACS), and who were shown in this communication is, therefore, twofold: to have infarcts in the distribution of branches of first, to alert the clinician to another cerebro- the middle cerebral artery in the right cerebral vascular cause ofACS; and, secondly, to advance hemisphere. In clinical practice, the vast some preliminary thoughts on the anatomy of majority of ACS result from metabolic en- cerebral dysfunction in ACS. cephalopathies, intoxications, withdrawal states, infections, head trauma, or post-ictal states (Cohen, 1953; Engel and Romano, 1959; CASE 1 Lipowski, 1967; Adams and Victor, 1974). ACS A 61 year old, right-handed man was admitted be- have occasionally been reported as dominating cause of the sudden onset of agitated confusion. He of infarcts in the was living alone and effectively taking care of his http://jnnp.bmj.com/ the clinical presentation shopping and cooking until the day before admission distribution of the posterior (Horenstein et al., when he was discovered by his landlady in a dis- 1967; Medina et al., 1974) or of the anterior oriented, incoherent and agitated state, banging on (Hyland, 1933; Amyes and Nielsen, 1955) the doors and shouting in the middle of the night. cerebral arteries. However, except for a brief At admission, the vital signs were unremarkable and description by Pearce and Miller (1973), of the general physical examination was within normal confusion resulting from right parietal lesions, limits except for a systolic ejection murmur. The ACS are not recognized as major sequellae of neurological examination found the patient to be on October 2, 2021 by guest. infarcts in the distribution of the middle cerebral awake but to have a severely diminished attention artery. Furthermore, since the target in the span, being able to repeat only two numbers for- nervous of most insults ward. Minor and irrelevant stimuli elicited dramatic central system causing orienting responses and resulted in extreme distracti- 1 This work was supported in part by grants NB 06209 from the National Institute of Neurological Disease and Blindness, and bility. The stream of thought was incoherent; the NS 12307 and NS-00010 from the National Institute of Health. ability to grasp environmental cues and to react 2 Address for correspondence: M-M Mesulam, Harvard Department was There was no of Neurology, Beth Israel Hospital, 330 Brookline Avenue, Boston, accordingly severely compromised. Mass. 02215, U.S.A. concern for this incapacitating change in mental (Accepted 19 August 1975.) status. The quantity of activity varied from sluggish- 84 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.1.84 on 1 January 1976. Downloaded from Acute contfusional states with right middle cerebral artery infarctions 85 t. _A B Protected by copyright. FIGURE A, B, and C are right lateral radioisotope scans. The anterior part of the brain is to the right. A: case 1; B: case 2; C: case 3. D is a computerized axial tomography picture of case 3. Arrows point http://jnnp.bmj.com/ towards the site of abnormality. ness to agitation for which the patient required function, or plantar responses could be detected. physical restraints. Several examiners thought that The patient was incontinent, unkempt, and would auditory hallucinations were present. The patient not use utensils for eating. was disoriented in all spheres. He had difficulty in In the next few days, the agitation disappeared naming objects presented in the visual, auditory, or completely and the patient became amiable and on October 2, 2021 by guest. tactile modes and his speech contained paraphasias placid. In the next month, the anomic aphasia also and circumlocutions. He could read but could not improved considerably; however, the attention span write. Extreme distractibility rendered the remainder remained severely compromised and there was no of the mental status examination unreliable. The ability to maintain a coherent stream of thought. gait was retropulsive and unsteady. There was Routine laboratory investigations were unremark- minimal reaction to visual stimuli in the left hemi- able. A technetium brain scan, which was normal at field but the differentiation could not be made admission, revealed an area of increased uptake in between inattention and hemianopsia. No other the right parieto-occipital region 10 days later abnormalities of cranial nerves, sensorimotor (Figure, A). A four-vessel arteriogram showed the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.1.84 on 1 January 1976. Downloaded from 86 Marek-Marsel Mesulam, Stephen G. Waxman, Norman Geschwind, and Thomas D. Sabin right angular branch of the middle cerebral artery to in all spheres. Details of a simple story could not be be occluded. A pneumoencephalogram was consis- recalled five minutes later. Paraphasic errors as well tent with mild cerebral atrophy. as left-right confusion were noted. Cranial nerves and all sensorimotor functions, including the plantar CASE 2 response, were normal. There was no concern for this illness, despite the additional retropulsive gait A 65 year old, right-handed alcoholic man was and incontinence. Abnormal laboratory findings brought to the accident floor by his landlord who consisted of a blood urea nitrogen of 12.1 mmol/l, reported the onset of confusion and incoherent blood glucose of 16.3 mmol/l, bilirubin of23.9 tLmol/l. speech four days previously. Before that time, the On the third hospital day, a brain scan showed an patient had been entirely self sufficient. The general area of increased uptake in the right inferior frontal medical examination was essentially unremarkable. gyrus (Figure, C, D); this area was not present on a The patient was fully awake but extremely inattentive repeat brain scan six months later. A right carotid and easily distractible. Neither a coherent stream of arteriogram was negative. A computerized axial thought nor a coherent sequence of goal-directed tomography of the brain localized an area in the behaviour could be maintained. He was initially inferior frontal gyrus of the right hemisphere with a agitated but this rapidly subsided into a state of density profile consistent with infarction. Six placidity. Disorientation was noted in all spheres. months after this admission, the patient was less Knowledge of remote and current world events, the confused but continued to display irritable sluggish- ability to memorize, calculate, and abstract were all ness. severely impaired. There was a mild naming diffi- In summary, we have described three right-handed in of culty and also dysgraphia the absence alexia, elderly male patients who presented with the acute Protected by copyright. finger agnosia, or left-right confusion. Constructions onset ofa confusional state. The salient and common were poorly performed. He showed severe deficits in symptoms included inattentiveness to relevant his ability to make use of such common objects as stimuli, distractibility by irrelevant stimuli, inability matches or eating utensils. The gait was unsteady and to grasp the immediate situation so as to react to it retropulsive and urinary incontinence was occasion- appropriately, inability to maintain either a coherent ally present. The patient showed no concern for stream of thought or a coherent sequence of goal his predicament. Neglect of visual stimuli as well as directed behaviour, disorientation, anomia, dys- minor deficits of graphaesthesia and stereognosis graphia, abnormal gait, incontinence, difficulty in could intermittently be demonstrated on the left. using common objects, and lack of concern for the No elementary deficits in cranial nerve or in sensori- illness. The level of arousal was never significantly motor functions could be demonstrated. Laboratory depressed and the initial agitation rapidly resolved investigations were essentially normal. A technetium into a state of sluggishness. The deficits in memor- scan of the brain revealed an area of increased izing and in intellectual functions which were also isotope uptake in the right parietotemporal region elicited may have been secondary to the inattentive- (Figure, B); this abnormality disappeared 16 days ness during the testing situation. The lateralizing after admission. The patient was unchanged at dis- neurological
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