Diagnostic approach for adult mitochondriopathy with limited resources.

CMYK 511 lesions (infarcts), in the absence of supratentorial involvement or antecedent illness indicated posterior circulation stroke as the aetiology. The distribution of these ischemic lesions was multifocal, in the areas supplied by left superior cerebellar, left anterior inferior cerebellar and the penetrating left pontine branches of basilar arteries, thus involving the middle and distal posterior circulation territories (apart from the nonterritorial right paravermal infarct). Miyakita et al. reported the first case of transient cerebellar mutism after brainstem infarction following traumatic injury of right vertebral artery. However, our patient had involvement of both brainstem and cerebellar structures in the non-traumatic context. It is noteworthy that there was transient disturbance in the level of consciousness at the onset along with transient right hemiplegia and gait ataxia in both cases. This finding was in agreement with the reported association of cerebellar mutism with a spectrum of neurological deficits including pyramidal, cerebellar and eye movement signs. We believe that a complex interaction of cerebellar and brainstem involvement might be the cause of mutism in our patient. One of the suggested mechanisms for postoperative cerebellar mutism includes brainstem ischemia and subsequent edema, to account for the transient nature of the syndrome. The vascular basis of this syndrome in the nonsurgical setting is better exemplified by our report. The good outcome of the speech disorder (including the improvement of dysarthria with the return of near normal speech during the subsequent period of observation), despite the presence of established infarcts, could be attributed to unilateral brainstem infarction, resolution of edema or neuronal plasticity. The behavioral disturbance also normalized with the resolution of mutism. Hence recognizing this syndrome is important in informing the parents about the prognosis and rehabilitation of speech and behavioral disorder, as most of these cases were encountered in the pediatric age group.