Akinetic mutism after fourth ventricle choroid plexus papilloma: Treatmentwith a dopamine agonist

BACKGROUND Akinetic mutism is a behavioral state wherein a patient seems to be awake b ut does not move or speak. Several patients are reported to have developed mutism after posterior fossa surgery. We present a patient who developed ak inetic mutism after total excision of a choroid plexus papilloma of the fou rth ventricle, and who was treated with bromocriptine, CASE DESCRIPTION An 18-year-old woman was admitted with akinetic mutism, which had developed 6 days after posterior fossa surgery. She had had no neurologic deficit in the first 5 days after surgery and could communicate with her family. Desp ite antioedematous therapy and daily lumbar punctures to drain cerebrospina l fluid, there was no clinical improvement after she entered the akinetic m ute state. Brain magnetic resonance revealed ventriculomegaly; brain single photon emission computed tomography revealed bilateral reduction of perfus ion in the frontal region. Because daily lumbar drainage did not result in clinical improvement, shunt placement was not considered. Bromocriptine the rapy was begun at a dose of 2 x 2.5 mg; 24 hours later, the patient started to speak and move her upper extremities. Further improvement occurred over the following week when the dose was increased to 3 x 2.5 mg, Bromocriptin e was replaced with a placebo to determine whether the neurologic improveme nt was caused by the medicine. The patient's neurologic status deteriorated progressively; therefore, bromocriptine was restarted and she was discharg ed from the hospital. During the 6 months of follow-up, the patient has rem ained in good health. CONCLUSIONS The etiology of akinetic mutism is not clear. Monoaminergic pathways, parti cularly dopaminergic cell groups, are most probably involved in this syndro me, because bromocriptine has a dramatic effect on these patients, as demon strated in our case. (C) 1999 by Elsevier Science Inc.