Buge A, Escourolle R, Rancurel G, Poisson M
Rev Neurol (Paris). 1975 Feb;131(2):121-31.
The authors describe three pathological cases of akinetic mutism with, as a common basic lesion, bilateral infarction of the cingulate gyrus secondary to aneurysm of the anterior communicating artery (case n degrees 1), to a huge olfactory meningioma (case n degrees 2), both operated on, and to atheromatous occlusion of the anterior cerebral arterial system (case n degrees 3). These three cases enable a variety of "anterior and waking" akinetic mutism to be described which is unusual enough to be compared with other mesencephalic and diencephalic aspects of this syndrome. It is in fact an akinetic mutism characterized by: a certain dissociation in its non-response to various stimuli, a particularly marked appearance of wakefulness when day-time alertness is considered, conservation of the waking-sleeping rhythm, perception and reaction unpredictable and paradoxical in both degree and quality, complete absence of any spontaneous verbal communication in contrast to relative break-down of solicited communication which is infrequent, uncertain and unresponsive to the usual methods of stimulation, without any possibility of a code. In addition, there is a remarkable mimic and segmental general akinesia, resistant to the usual nociceptive stimuli, but sensitive to slight excitation of the manual and oral zones. Besides this special akinetic mutism, there are variously systematised signs, mostly asymmetrical, indicating lesion of the cortico-sub-cortical frontal structures bordering on the gyrus cinguli. This unusual behaviour pattern corresponds in these three cases to extensive anterior bilateral ischemic lesions of the cingulate gyrus regularly associated with bilateral infarctions confined to the medial aspect of F1 in the superficial territory of the two anterior cerebral arteries, to possible neurosurgical changes (ablation of the right frontal pole) and to compressive or ischaemic lesions of the gyrus rectus. These exclusively cortico-sub-cortical associated lesions are in contrast with the remarkably intact caudate nuclei, the pallidal, thalamic, hypothalamic and septal formations and the anterior pillars of the fornix. These findings compared with the results of experimental research carried out by M. Kennard, help, if help is needed, to resolve the apparent contradictions between the effects of therapeutic cingulectomies or cingulotomies and the scanty pathological data already available in cerebral vascular pathology.
作者描述了3例运动不能性缄默症的病理病例，其共同的基本病变为：1例继发于前交通动脉瘤（病例1）、1例继发于巨大嗅沟脑膜瘤（病例2，均接受了手术）、1例继发于大脑前动脉系统粥样硬化闭塞（病例3）的双侧扣带回梗死。这3例病例使我们能够描述一种不同类型的“前脑性及清醒性”运动不能性缄默症，其罕见程度足以与该综合征的其他中脑和间脑方面表现相比较。实际上，这是一种运动不能性缄默症，其特点为：对各种刺激无反应存在一定分离；从日间警觉性来看，清醒状态表现尤为明显；觉醒 - 睡眠节律保存；感知和反应在程度和性质上不可预测且自相矛盾；与相对较少、不确定且对常规刺激方法无反应的被诱导交流的相对破坏相反，完全没有任何自发言语交流，且无法编码。此外，存在显著的模仿性和节段性全身运动不能，对常规伤害性刺激有抵抗，但对手部和口腔区域的轻微刺激敏感。除了这种特殊的运动不能性缄默症外，还有各种不同程度系统化的体征，大多不对称，提示扣带回周围皮质 - 皮质下额叶结构受损。在这3例病例中，这种不寻常的行为模式对应于双侧扣带回广泛的前部缺血性病变，这些病变常与局限于双侧大脑前动脉浅部区域F1内侧的双侧梗死相关，还可能与神经外科手术改变（右额极切除）以及直回的压迫性或缺血性病变有关。这些仅涉及皮质 - 皮质下的相关病变与尾状核、苍白球、丘脑、下丘脑、隔区结构以及穹窿前柱显著完整形成对比。将这些发现与M. 肯纳德所进行的实验研究结果相比较，如果需要的话，有助于解决治疗性扣带回切除术或扣带束切断术的效果与脑血管病理学中已有的少量病理数据之间明显的矛盾。
