Caudal Cingulate Infarction Manifesting Astasia
A 58-year-old male with a history of hypertension and diabetes mellitus presented to our emergency room. He complained of dysarthria and inability to sit, stand and walk since his awakening. On admission, he was alert and oriented. He was slightly dysarthric. His Mini-Mental State Examination score was 30. He showed neither hemispatial neglect nor disconnection syndrome. Muscle strength of all extremities and the trunk was not decreased. On sensory examination, vibratory sensation was slightly decreased on both feet, which was attributed to diabetes mellitus. Thermal, pinprick and positional sensation was perceived normally in all extremities and trunk. The finger-to-nose test revealed terminal dysmetria in the right arm. However, the heel-to-shin test showed no asymmetry. Rapid alternating hand movement was not disturbed on both sides. Deep tendon reflexes were normoactive without pathological reflexes. He did not show any resting or intentional tremor nor asterixis. When he attempted to sit, he grasped the bed rails only with both hands to pull himself up without using his axial and leg muscles, but retropulsion occurred soon after detaching his hands from the bed rails. When tested lying on the bed, he could maintain his legs elevated for more than 10 s. However, he could not stand by himself unless his caregiver supported him.\nCT of the brain did not show any intracranial hemorrhage. Then, an MRI of the brain was performed and diffusion-weighted imaging showed a high-intensity lesion at the medial frontal lobe on the left side (fig. ). A sagittal section of the double inversion recovery sequence revealed a high-intensity lesion at the cingulate gyrus between the VCA and VCP line and a corpus callosum body (fig. ).\nAfter 3 weeks of rehabilitation, he could keep standing and walk freely without assistance. His gait was not broad-based and the steps were regular in amplitude and direction. However, when standing on one foot and walking in tandem gait, lateropulsion to the right side persisted. With his eyes closed, lateropulsion to the right remained. After discharge, he could return to work, although the slight lateropulsion on tandem gait and standing on one foot persisted even at 1 year after onset.