A Interesting case of Dysarthria

an interesting case of

dysarthria

dr.arul selvan unitpresenter: dr.m.ramesh babu

brief history

• Mr.X 68 yrs old male presented with ℅

• Fever 2 days

• H/o LOC followed by fall in the washroom @ 7

am on 14/12/17

• After the fall patient started ℅ weakness in Rt.

UL&LL

• No h/o headache/neck pain/ jerky movements

of limbs/ stiffening of the limbs/ starring look/

irrelevant talks/ incontinence/ tongue bite

• H/o brief episodes of Dysarthria ( Saliavation-

Complete Mute - Dysarthria - Normal) next day

after the fall, lasts for 5-10 minutes, a/w

swallowing difficulty - mostly while eating the

food

• Took him to the local hospital - CT Brain was

done which showed SDH Rt. fronto-temporo-

parietal region

• Brought here for further evaluation

• Past History: H/o Rt. Hemiparesis - Ischemic

stroke 25 yrs back

• H/o C.N III palsy 4 yrs back ? Diabetic

• H/O Diabetes - 10 yrs

• H/o HTN - newly diagnosed

• Family H/o : Father had h/o CVA

• Personal H/o: Ex-smoker - left 5 yrs back

history summary

• Mr. X 68 yrs elderly male, DM/HTN/Ex

Smoker presented with fever 2 days, LOC

followed by head injury with weakness of Rt.

hemiparesis without facial involvement with

brief episodes of dysarthria, without jerky

movements, altered sensorium, irrelevant

talks, starring look, with h/o old Rt.

hemiparesis

• Possibilites:

• Seizure - Todd palsy

• Seizure at the onset of Stroke

• Cervical myelopathy with Seizure / TIA

• ?SDH - due compression effect

on examination

• GPE: well built and nourished

• NO P I C C L E

• No Neurocutaneous markers

• Vitals: BP: 140/90mmhg, PR- 84/min, Temp -

N

cns examination

• Patient conscious , alert, well oriented to time

/ place/person

• MMSE - 28/30

• Speech - fluency, comprehension, repetition ,

naming, reading, copying - N

• Pupils - B/L 3mm reactive

• Fundus: Normal

• EOM - full

• No facial lag

• Tongue and palate - normal

• Gag & Jaw reflex - N

• Motor system : Tone - spasticity Rt.side

• Power : 4/5 5/5

• 4/5 5/5

• DTR’S - Rt. BJ, SJ - Brisk

• Plantar : Extensor Rt. Flexor Lt.

• Sensory System - No deficit

• No cerebellar signs

• No meningeal signs

• No cervical pain or ROM

investigations

• CBC - N

• RFT - N

• LFT - N

• S.Na, K+ - N

• S.Cholesterol - 300mg/dl

• HbA1c - 11.9%

• Blood glucose- 386mg/dl

• CT Brain - SDH Rt. Fronto-temporo-parietal

region

• MRI C.Spine - C4-5, C5-6 disc bulging with

compression of C5/6 roots on R>L with facet

joint hypertrophy

• Patient treated with Inj.Levipil, Inj.Strocit,

T.Gabantin and Vitamins

• Pt. Improved in power within 2 days, No

further Dysarthric episodes - Discharged

• Again Readmitted on 22.12.2107 with ℅

Paroxysmal Dysarthria - 2 times lasting for 10-

15 times and recovers fully.

• No other associated symptoms

• Further evaluated with MRI brain and MRA

IMAGING

• Escalated Levipil dose - Not controlled

• Had 2 more brief episodes in Ward on the

same day

• Started on T. Ecosprin 75mg OD and

T.Clobazam 10mg BD

• No further episodes

• Discharged

Paroxysmal dysarthria

• Seizure vs TIA ?Etiology

• ?Reflex seizure

• ? Due to SDH

• ? Hyperglycemia induced seizure

mechanism of paroxysmal

dysarthria• Following hypothesis as to the mechanism of the

paroxysmal attacks:

• The fact that the attacks are an early symptom

suggests that they may correspond to the earlier

stages of demyelination/ axonal injury

• During this phase it may well be that the axons,

though still capable of functioning normally in the

various facilitating and inhibiting systems, become

very vulnerable to changes in the internal environment

and that some minor, and reversible, change might

cause them temporarily to suspend function, which

they resume as the change passes off.

• Appears to be highly sensitive to the effects of

overbreathing. Since overbreathing is known to

decrease cerebral blood flow , small fall in the

blood supply producing, presumably, a minor

degree of hypoxia, to which damaged neurones

are abnormally sensitive.

• Biochemical and/or vascular changes responsible

for transient neurological disturbances,

• Emotion / stress - vasospasm - triggers

symptoms

Causes of Dysarthria• Neurologic disorders with dysarthria as a

symptom:

• Stroke: cerebrovascular ischemic disorders

• - Cerebellar infarction

• - Lacunar infarction

• - Subcortical ischemic vascular dementia

• - Vertebrobasilar ischemia

• Epileptic disorders - Lingual epilepsia partialis

continua - Congenital bilateral perisylvian

syndrome with partial epilepsy - Benign

childhood epilepsy with centrotemporal spikes

• Trauma to the central nervous system

• Encephalitis - Encephalitis lethargica - Herpes

simplex encephalitis

• Brainstem disorders - Basilar-type migraine -

Brainstem encephalitis - Brainstem tumors -

Central pontine myelinolysis

• Drug-induced dysarthria:

• Antiepileptic drugs: phenytoin

• Anticancer agents: irinotecan

• Benzodiazepines

• Lithium neurotoxicity

• Neuroleptic drugs

• Paroxetine, a selective serotonin reuptake inhibitor

• Exposure to toxins and metals: • Mercury poisoning

• Botulism • Nerve agent poisoning

• Demyelinating diseases - Multiple sclerosis -

Pelizaeus-Merzbacher disease

• Myasthenia gravis

• Cranial nerve lesions - Aneurysms of

extracranial internal carotid artery

• Dysarthria in metabolic diseases with

neurologic manifestations: • 2-Hydroxyglutaric

aciduria • Ornithine transcarbamylase

deficiency

• THANK YOU