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Clonic Perseveration vs Stereotypy Phenomenology

Clonic Perseveration vs Stereotypy Phenomenology To the Editor We read with interest the report by Pandey and Sarma1 of a patient with an acute left thalamic infarction who developed seemingly purposeless tapping movements in the right hand. In the accompanying video, the movement on day 6 was confined to the right hand, with wrist flexion extension at 4 to 5 Hz and index finger extension.1 On day 10, the movement progressed to include wrist flexion extension, elbow flexion extension, and shoulder internal-external rotation. On day 21, with reduced severity, the movement was again of wrist flexion extension. On day 28, the movement was limited to fingers flexion. At 1-month follow-up, the movement was mild but seemed to be triggered by right index finger extension. The phenomenology was interpreted as a stereotypy. Stereotypy is a non–goal-directed movement pattern that is repeated continuously for a period in the same form and on multiple occasions and which is typically distractible.2 It is a “looped’’ motor pattern occurring intermittently. Pathophysiologically complex stereotypy has been reported following a basal ganglia lesion2 but, to our knowledge, stereotypy following acute thalamic infarct has not been described.1 In the provided video, the movement patterns and involved body parts varied with time and there was no obvious distractibility. We propose an alternative interpretation of such phenomenology as clonic perseveration. Clonic perseveration is a term coined by Liepmann to describe a form of motor perseveration in which inappropriate repetition of an action, once initiated, occurs in the absence of an ongoing cue; the ability to change in response to a new cue is preserved.3,4 It has been documented in thalamic infarction3,4 and Japanese encephalitis.5 We previously reported 4 patients with clonic perseveration following thalamic infarction having developed rhythmic, stereotyped, and repetitive movements induced by passive limb movements or occurring spontaneously.3 The pattern of movement varied over intervals of minutes to days, and it was associated with aspontaneity, mutism, and grasp reflexes.3 Clonic perseveration results from disconnection of the prefrontal cortico-basal ganglia-thalamo-cortico loops causing interruption of dorsolateral prefrontal projections at the thalamic level, which is important for the termination of motor plans.3 Its reversibility is hypothetically related to improved perfusion of the thalamus and frontal cortex.5 Clonic perseveration differs from stereotypy in that it can occur in response to external cues or repetition of passive movements and can be suppressed temporarily on command. The importance of recognizing both movement disorders following basal ganglia or thalamus lesions is to avoid misdiagnosis and treatment for tremor or seizure.3 Back to top Article Information Corresponding Author: Victor S. C. Fung, MBBS(Hons), PhD, FRACP, Movement Disorders Unit, Department of Neurology, Westmead Hospital, Westmead, NSW 2145, Australia (vfung@usyd.edu.au). Published Online: December 28, 2015. doi:10.1001/jamaneurol.2015.3921. Conflict of Interest Disclosures: None reported. References 1. Pandey S, Sarma N. Stereotypy after acute thalamic infarct. JAMA Neurol. 2015;72(9):1068.PubMedGoogle ScholarCrossref 2. Edwards MJ, Lang AE, Bhatia KP. Stereotypies: a critical appraisal and suggestion of a clinically useful definition. Mov Disord. 2012;27(2):179-185.PubMedGoogle ScholarCrossref 3. Fung VS, Morris JG, Leicester J, Soo YS, Davies L. Clonic perseveration following thalamofrontal disconnection: a distinctive movement disorder. Mov Disord. 1997;12(3):378-385.PubMedGoogle ScholarCrossref 4. Wells M, Jacques R, Montero Odasso M. Thalamic infarct presenting as catastrophic life-threatening event in an older adult. Aging Clin Exp Res. 2011;23(4):320-322.PubMedGoogle ScholarCrossref 5. Ono Y, Manabe Y, Sakai K, Hayashi Y, Abe K. Clonic perseveration in the subacute stage of Japanese encephalitis. J Neurol Sci. 2006;251(1-2):107-109.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Neurology American Medical Association

Clonic Perseveration vs Stereotypy Phenomenology

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6149
eISSN
2168-6157
DOI
10.1001/jamaneurol.2015.3921
Publisher site
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Abstract

To the Editor We read with interest the report by Pandey and Sarma1 of a patient with an acute left thalamic infarction who developed seemingly purposeless tapping movements in the right hand. In the accompanying video, the movement on day 6 was confined to the right hand, with wrist flexion extension at 4 to 5 Hz and index finger extension.1 On day 10, the movement progressed to include wrist flexion extension, elbow flexion extension, and shoulder internal-external rotation. On day 21, with reduced severity, the movement was again of wrist flexion extension. On day 28, the movement was limited to fingers flexion. At 1-month follow-up, the movement was mild but seemed to be triggered by right index finger extension. The phenomenology was interpreted as a stereotypy. Stereotypy is a non–goal-directed movement pattern that is repeated continuously for a period in the same form and on multiple occasions and which is typically distractible.2 It is a “looped’’ motor pattern occurring intermittently. Pathophysiologically complex stereotypy has been reported following a basal ganglia lesion2 but, to our knowledge, stereotypy following acute thalamic infarct has not been described.1 In the provided video, the movement patterns and involved body parts varied with time and there was no obvious distractibility. We propose an alternative interpretation of such phenomenology as clonic perseveration. Clonic perseveration is a term coined by Liepmann to describe a form of motor perseveration in which inappropriate repetition of an action, once initiated, occurs in the absence of an ongoing cue; the ability to change in response to a new cue is preserved.3,4 It has been documented in thalamic infarction3,4 and Japanese encephalitis.5 We previously reported 4 patients with clonic perseveration following thalamic infarction having developed rhythmic, stereotyped, and repetitive movements induced by passive limb movements or occurring spontaneously.3 The pattern of movement varied over intervals of minutes to days, and it was associated with aspontaneity, mutism, and grasp reflexes.3 Clonic perseveration results from disconnection of the prefrontal cortico-basal ganglia-thalamo-cortico loops causing interruption of dorsolateral prefrontal projections at the thalamic level, which is important for the termination of motor plans.3 Its reversibility is hypothetically related to improved perfusion of the thalamus and frontal cortex.5 Clonic perseveration differs from stereotypy in that it can occur in response to external cues or repetition of passive movements and can be suppressed temporarily on command. The importance of recognizing both movement disorders following basal ganglia or thalamus lesions is to avoid misdiagnosis and treatment for tremor or seizure.3 Back to top Article Information Corresponding Author: Victor S. C. Fung, MBBS(Hons), PhD, FRACP, Movement Disorders Unit, Department of Neurology, Westmead Hospital, Westmead, NSW 2145, Australia (vfung@usyd.edu.au). Published Online: December 28, 2015. doi:10.1001/jamaneurol.2015.3921. Conflict of Interest Disclosures: None reported. References 1. Pandey S, Sarma N. Stereotypy after acute thalamic infarct. JAMA Neurol. 2015;72(9):1068.PubMedGoogle ScholarCrossref 2. Edwards MJ, Lang AE, Bhatia KP. Stereotypies: a critical appraisal and suggestion of a clinically useful definition. Mov Disord. 2012;27(2):179-185.PubMedGoogle ScholarCrossref 3. Fung VS, Morris JG, Leicester J, Soo YS, Davies L. Clonic perseveration following thalamofrontal disconnection: a distinctive movement disorder. Mov Disord. 1997;12(3):378-385.PubMedGoogle ScholarCrossref 4. Wells M, Jacques R, Montero Odasso M. Thalamic infarct presenting as catastrophic life-threatening event in an older adult. Aging Clin Exp Res. 2011;23(4):320-322.PubMedGoogle ScholarCrossref 5. Ono Y, Manabe Y, Sakai K, Hayashi Y, Abe K. Clonic perseveration in the subacute stage of Japanese encephalitis. J Neurol Sci. 2006;251(1-2):107-109.PubMedGoogle ScholarCrossref

Journal

JAMA NeurologyAmerican Medical Association

Published: Feb 1, 2016

References