Transient mutism due to posterior circulation infarction.

Sir, Verbal mutism is described as the speechless state in a cognitively alert patient, without buccolingual apraxia. It has been a well-documented complication of resective surgery for posterior fossa tumors, especially in children. 1,2 However, there are only few reports of posterior fossa mutism that are not due to neuro-trauma or neuro-surgical trauma. 3-5 We report the case of transient mutism in the setting of non-traumatic posterior circulation infarction. An 11-year-old boy, who was right handed, developed recurrent bouts of vomiting, giddiness, right hemiparesis, left upper limb incoordination and loss of speech, one day prior to presentation. There was no preceding history of fever, headache, neck pain or trauma. On admission, his blood pressure was normal. He was drowsy; moving left upper and lower limbs spontaneously , but could not vocalize any phoneme. He had evidence of unilateral pyramidal sign in the form of right extensor plantar response. The following day, he was more alert. He had left hemiataxia on testing for limb coordination with repeated coaxing, but no nystagmus. Though mute and withdrawn , he exhibited inconsolable whining for several hours. Swallowing, chewing, facial, tongue and neck movements were normal. Diagnostic investigation revealed normal findings on serum biochemistry, hemogram, erythrocyte sedimentation rate, sickling cell test, lipid profile and anti-phospholipid an-tibody work-up. Electro-cardiogram, echocardiography, carotid and vertebral doppler scan and X ray cervical spine were normal. Plain and contrast enhanced brain computed tomogra-phy imaging (CT scan) obtained on the day of admission, revealed multiple hypodensities involving part of left cerebellar hemisphere, right paravermal region, and left rostral pons. Brain magnetic resonance imaging (MRI) performed subsequently revealed hyperintense areas involving left superior cerebellar hemisphere, right paravermal region, left middle cerebellar peduncle and baso-tegmental region of left rostral pons on T2WI and FLAIR sequences (Figures a, b, c). Magnetic resonance angiogram (arterial and venous study) of the intracranial vasculature was normal. He was treated with aspirin and was placed on regular rehabilitation programme. There was gradual improvement of right hemiparesis in the first week. He could verbalize monosyllables in the third week and ill-articulated single words in the fourth week of illness. The subsequent slurred speech was slow and the words were uttered laboriously with strained voice and audible respiration. Gait was ataxic and broad based requiring one-person assistance. When examined two months later, his speech was near normal, the behavioral alteration had subsided and he could walk without assistance. Repeat cranial …