Incontinência do choro e infarto protuberancial unilateral

Oliveira-Souza, Ricardo de; Figueiredo, Wagner Martignoni de; Andreiuolo, Pedro ângelo

doi:10.1590/S0004-282X1995000400024

Resumos

O presente estudo trata do caso de um paciente que apresentou incontinência do choro e hemiplegia direita por infarto ventroprotuberancial paramediano detectado pela RNM. O caráter circunscrito da lesão foi endossado pela normalidade dos potenciais evocados sômato-sensitivos e auditivos de curta-latência. Os episódios de choro desapareceram poucos dias depois do início do tratamento com doses baixas de imipramina. Discutimos o choro e riso patológicos como forma de incontinência da mímica resultante de desconexão límbico-motora, enfatizando a impropriedade de incluí-los na síndrome pseudobulbar, uma vez que dependem de correlatos anatômicos e funcionais distintos.

síndrome pseudobulbar; choro e riso patológico; hemiplegia motora pura; imipramina

A 64-year-old man presented with pathologic crying and right hemiplegia due to a unilateral pontine infarct from probable branch disease of the basilar artery. The circumscribed nature of the lesion was supported by MRI and short-latency evoked potentials. The weeping spells ceased after a few days of imipramine in low doses. Pathologic laughing and crying can be viewed as a limbic-motor disconnection syndrome, in which the faciovocal motor system is released from forebrain afferents carrying information of emotional content. The inclusion of pathologic laughing and crying in the syndrome pseudobulbar palsy is inaccurate and misleading, since each is related to distinct functional and anatomic systems intrinsic to the human brainstem.

pseudobulbar paralysis; pathologic laughing and crying; pure motor hemiplegia; imipramine

Incontinência do choro e infarto protuberancial unilateral

Incontinence of crying and unilateral pontine infarct

Ricardo de Oliveira-Souza^I; Wagner Martignoni de Figueiredo^II; Pedro ângelo Andreiuolo^III

^INeurologista, Professor Assistente, Serviço de Clínica Médica C (Prof. Omar da Rosa Santos), Hospital Universitário Gaffrée e Guinle, UNI-RIO (HUGG-UNI-RIO)

^IIClínico Geral, Professor Adjunto, Clínica Médica C (Prof. Omar da Rosa Santos), HUGG -UNI RIO

^IIIRadiologista, Hospital da Beneficiência Portuguesa (Niterói, RJ) e X LABS (RJ)

RESUMO

O presente estudo trata do caso de um paciente que apresentou incontinência do choro e hemiplegia direita por infarto ventroprotuberancial paramediano detectado pela RNM. O caráter circunscrito da lesão foi endossado pela normalidade dos potenciais evocados sômato-sensitivos e auditivos de curta-latência. Os episódios de choro desapareceram poucos dias depois do início do tratamento com doses baixas de imipramina. Discutimos o choro e riso patológicos como forma de incontinência da mímica resultante de desconexão límbico-motora, enfatizando a impropriedade de incluí-los na síndrome pseudobulbar, uma vez que dependem de correlatos anatômicos e funcionais distintos.

Palavras-chave: síndrome pseudobulbar, choro e riso patológico, hemiplegia motora pura, imipramina.

SUMMARY

A 64-year-old man presented with pathologic crying and right hemiplegia due to a unilateral pontine infarct from probable branch disease of the basilar artery. The circumscribed nature of the lesion was supported by MRI and short-latency evoked potentials. The weeping spells ceased after a few days of imipramine in low doses. Pathologic laughing and crying can be viewed as a limbic-motor disconnection syndrome, in which the faciovocal motor system is released from forebrain afferents carrying information of emotional content. The inclusion of pathologic laughing and crying in the syndrome pseudobulbar palsy is inaccurate and misleading, since each is related to distinct functional and anatomic systems intrinsic to the human brainstem.

Key words:pseudobulbar paralysis, pathologic laughing and crying, pure motor hemiplegia, imipramine.

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Full text available only in PDF format.

Agradecimento - Agradecemos aos Drs. Dayse Lúcia Gusmão pelas críticas ao manuscrito, Andreas Manger, pelo texto de Magnus (Referência 38) e Maurício Klajnberg, pelos exames eletrofisiológicos; à Prof. Marlene Soares Dos Santos pela revisão do resumo em inglês e aos funcionários das bibliotecas do Instituto Oswaldo Cruz (IOC-MS) e do Centro de Ciências da Saúde da Universidade Federal do Rio de Janeiro (CCS-UFRJ), pela eficiência na obtenção dos textos originais.

Aceite: 13-março-1995.

Dr. Ricardo de Oliveira Souza - Rua General Belford 226 - 20961-000 Rio de Janeiro RJ - Brasil.

1. Allman P. Crying and laughter after brain damage: a confused nomenclature. J Neurol Neurosurg Psychiatry, 1989, 52: 1439-1440.
2. Aring CD. Supranuclear (pseudobulbar) palsy. Arch Intern Med. 1965, 115: 198-199.
3. Andersen C. Crise de rire spasmodique avant décès: hemorrhagic thalamique double. J Beige Neurol Psychiat, 1936, 36: 223-227.
4. Andersen G, Ingeman-Nielsen M, Vestergaard K, Riis JO. Pathoanatomic correlation between poststroke pathological crying and damage to brain areas involved in serotoninergic neurotransmission. Stroke 1994, 25: 1050-1052.
5. Andersen G, Vestergaard K, Riis JO. Post-stroke pathological crying treated with the selective serotonin reuptake inhibitor, citalopram Lancet. 1993, 342: 837- 839.
6. Asfora WT, DeSalles AA, Abe M, Kjellberg RN. Is the syndrome of pathological laughing and crying a manifestation of pseudobulbar palsy ? J Neurol Neurosurg Psychiatry 1989, 52: 523-525.
7. Bassetti C, Bogousslavsky J, Barth A, Regli F. Paramedian pontine infarct: clinical- topographic correlation. Neurology 1993, 43: A159.
8. Bechterew W. Unaufhaltsames Lachen und Weinen bei Hirnaffectionen. Arch Psychiat Nervkrank 1894, 26: 791-817.
9. Besson G, Bogousslavsky J, Regli F, Maeder P. Acute pseudobulbar or suprabulbar palsy. Arch Neurol 1991, 48: 501-507.
10. Bogousslavsky J, Regli F. Capsular genu syndrome. Neurology 1990, 40: 1499-1502.
11. Bradley WG. MR of the brain stem: a practical approach. Radiology 1991, 179: 319-332.
12. Brissaud E. Sur le rire et le pleurer spasmodiques. In: Leçons sur le Maladies Nerveuses. Paris: G Masson, 1895, p 446-448.
13. Brissaud E. Rire et pleurer spasmodiques. Rev Neurol (Paris) 1900, 9:824-825.
14. Burzio F. Emiplegia con dolori ed accessi di riso spasmodico do rammollimento di nucleo lenticulare interessanti la capsula interna. Ann Freniatr Sci Affini 1900, 10: 140-148.
15. Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology 1989, 39: 1246-1250.
16. Caroscio JT, Cohen JA, Gudesblatt M. Amitriptyline in amyotrophic lateral sclerosis. N Engl J Med 1985, 313: 1478-1479.
17. Ceccaldi M, Poncet M, Milandre L, Rouyer C. Temporary forced laughter after unilateral strokes. Eur Neurol 1994, 34: 36-39.
18. Danek A, Bauer M, Fries W. Tracing of neural connections in the human brain by magnetic resonance imaging in vivo. Eur J Neurosci 1990, 2: 112-115.
19. Dejerine J. La paralysie pseudo-bulbaire. Journal des Practiciens 1914, 21: 406-408.
20. Dupré E, Devaux A. Rire et pleurer spasmodiques par ramollissement nucléo-capsulaire antérieur: syndrome pseudo-bulbaire par désintégration lacunaire bilatérale des putamens. Rev Neurol (Paris) 1901, 9: 919-926.
21. Féré C. Paralysie pseudo-bulbaire par lésion cérébrale bilatérale. Rev Méd (Paris) 1882, 11: 858-861.
22. Gloor P, Olivier A, Quesney LF, Andermann F, Horowitz S. The role of the limbic system in experiential phenomena of temporal lobe epilepsy. Ann Neurol 1982, 12: 129-144.
23. Geschwend J. Dissoziiertes Lachen und Weinen bei apoplektischen Insult. Fortschr Neurol Psychiat 1978, 46: 29-32.
24. Hanger HC. Emotionalism after stroke. Lancet 1993, 342: 1235-1236.
25. Helgason C, Wilbur A, Weiss A, Redmond KJ, Kingsbury NA. Acute pseudobulbar mutism due to discrete bilateral capsular infarction in the territory of the anterior choroidal artery. Brain 1988, 111: 507-524.
26. Holstege G. Descending motor pathways and the spinal motor system: limbic and non-limbic components. Progr Brain Res 1991, 87: 307-421.
27. Hopf HC, Tettenborn B, Kramer G. Pontine supranuclear facial palsy. Stroke 1990, 21: 1754-1757.
28. Huang CA, Broe G. Isolated facial palsy: a new lacunar syndrome. J Neurol Neurosurg Psychiatry 1984,47: 84-86.
29. Ironside R. Disorders of laughter due to brain lesions. Brain 1956, 79: 589-609.
30. Iwatsubo T, Kusuhara S, Kanemitsu A, Shimada H, Toyokura Y. Corticofugal projections to the motor nuclei of the brainstem and spinal cord in humans. Neurology 1990, 40: 309-312.
31. Karnosh LJ, Connor WH. Syphilitic pseudobulbar palsy with compulsive weeping. Am J Syph Gon Ven Dis 1936, 20: 115-123.
32. Langworthy OR, Hesser FH. Syndrome of pseudobulbar palsy: an anatomic and physiologic analysis. Arch Intern Med 1940, 65: 106-121.
33. Lawson IR, MacLeod RDM. The use of imipramine (Tofranil⁸) and other drugs in organic emotionalism. Br J Psychiatry 1969, 115: 281-285.
34. Lépine R. Note sur la paralysie glosso-labiée cérébrale a forme pseudo-bulbaire. Rev Mens Med Chir 1877, 1: 909-922.
35. Lépine R. Paralysie glosso-labiée cérébrale: rire et pleurer spasmodiques. Rev Méd (Paris) 1896, 16: 263-270.
36. Leys D, Lejeune JP, Bourgeois P, Blond S, Petit H. Syndrome pseudo-bulbaire aigu: infarctus bilatéral de la jonction capsule interne-corona radiata. Rev Neurol (Paris) 1985, 141: 814-818.
37. Lieberman A, Benson F. Control of emotional expression in pseudobulbar palsy. Arch Neurol 1977, 34: 717-719.
38. Magnus A. Fall von Aufhebung des Willenseinflusses auf einige Hirnnerven. Müller's Arch 1837, 258-266.
39. Mahoney FL, Barthel DW. Functional evaluation: the Barthel index. Md State Med J 1965, 14: 61-65.
40. Marie P. Des foyers de désintégration et de différents autres états cavitaires du cerveau. Rev Méd (Paris) 1901, 21: 281-298.
41. Mouton P, Rémy A, Cambon H. Rire spasmodique par lésion unilatérale du tronc cérébral. Rev Neurol (Paris) 1994, 150: 302-303.
42. Nighoghossian N, Ryvlin P, Trouillas P, Laharotte JC, Froment JC. Pontine versus capsular pure motor hemiparesis. Neurology 1993, 43: 2197-2201.
43. Poeck K. Pathological laughter and crying. In Vinken CI, Bruyn GW (eds). Handbook of Clinical Neurology, Vol 1 (45): Clinical Neuropsychology, Frederiks JAM, ed. Amsterdam: Elsevier B.V. 1985, p 219-225.
44. Poeck K, Pilleri G. Pathologisches Lachen und Weinen. Arch Neurol Psychiatr 1964, 92: 323-370.
45. Preskhorn SH. Pharmacokinetics of antidepressants: why and how they are relevant to treatment. J Clin Psychiatry 1993, 54 (Suppl 9): 14-34.
46. Ross ED, Rush AJ. Diagnosis and neuroanatomical correlates of depression in brain-damaged patients. Arch Gen Psychiatry 1981, 38: 1344-1354.
47. Schiffer RB, Cash J, Herndon RM. Treatment of emotional lability with low-dose tricyclic antidepressants. Psychosomatics 1983, 24: 1094-1096.
48. Sloan RL, Brown KW, Pentland B. Fluoxetine as a treatment for emotional lability after brain injury. Brain Inj 1992; 6: 315-319.
49. Tatemichi TK, Nichols FT, Mohr JP. Pathological crying: a pontine pseudobulbar syndrome. Ann Neurol 1987; 22: 133.
50. Udaka F, Yamao S, Nagata H, Nakamura S, Kameyama M. Pathologic laughing and crying treated with levodopa. Arch Neurol 1984, 41: 1095-1096.
51. Voogd J, Feirabend HKP, Schoen JHR. Cerebellum and precerebellar nuclei. In Paxinos G (ed). The Human Nervous System. San Diego: Academic Press, 1990, p 321-386.
52. Wali GM. "Fou rire prodromique" heralding a brainstem stroke. J Neurol Neurosurg Psychiatry 1993, 56: 209-210.
53. Wilson SAK. Some problems in neurology: II. Pathological laughing and crying. J Neurol Psychopathol 1924, 16: 299-333.
54. Yarnell PR. Pathological crying localization. Ann Neurol 1987, 22: 133-134.

Datas de Publicação

Publicação nesta coleção
20 Dez 2010
Data do Fascículo
Set 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Allman P. Crying and laughter after brain damage: a confused nomenclature. J Neurol Neurosurg Psychiatry, 1989, 52: 1439-1440.

[2] 2. Aring CD. Supranuclear (pseudobulbar) palsy. Arch Intern Med. 1965, 115: 198-199.

[3] 3. Andersen C. Crise de rire spasmodique avant décès: hemorrhagic thalamique double. J Beige Neurol Psychiat, 1936, 36: 223-227.

[4] 4. Andersen G, Ingeman-Nielsen M, Vestergaard K, Riis JO. Pathoanatomic correlation between poststroke pathological crying and damage to brain areas involved in serotoninergic neurotransmission. Stroke 1994, 25: 1050-1052.

[5] 5. Andersen G, Vestergaard K, Riis JO. Post-stroke pathological crying treated with the selective serotonin reuptake inhibitor, citalopram Lancet. 1993, 342: 837- 839.

[6] 6. Asfora WT, DeSalles AA, Abe M, Kjellberg RN. Is the syndrome of pathological laughing and crying a manifestation of pseudobulbar palsy ? J Neurol Neurosurg Psychiatry 1989, 52: 523-525.

[7] 7. Bassetti C, Bogousslavsky J, Barth A, Regli F. Paramedian pontine infarct: clinical- topographic correlation. Neurology 1993, 43: A159.

[8] 8. Bechterew W. Unaufhaltsames Lachen und Weinen bei Hirnaffectionen. Arch Psychiat Nervkrank 1894, 26: 791-817.

[9] 9. Besson G, Bogousslavsky J, Regli F, Maeder P. Acute pseudobulbar or suprabulbar palsy. Arch Neurol 1991, 48: 501-507.

[10] 10. Bogousslavsky J, Regli F. Capsular genu syndrome. Neurology 1990, 40: 1499-1502.

[11] 11. Bradley WG. MR of the brain stem: a practical approach. Radiology 1991, 179: 319-332.

[12] 12. Brissaud E. Sur le rire et le pleurer spasmodiques. In: Leçons sur le Maladies Nerveuses. Paris: G Masson, 1895, p 446-448.

[13] 13. Brissaud E. Rire et pleurer spasmodiques. Rev Neurol (Paris) 1900, 9:824-825.

[14] 14. Burzio F. Emiplegia con dolori ed accessi di riso spasmodico do rammollimento di nucleo lenticulare interessanti la capsula interna. Ann Freniatr Sci Affini 1900, 10: 140-148.

[15] 15. Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology 1989, 39: 1246-1250.

[16] 16. Caroscio JT, Cohen JA, Gudesblatt M. Amitriptyline in amyotrophic lateral sclerosis. N Engl J Med 1985, 313: 1478-1479.

[17] 17. Ceccaldi M, Poncet M, Milandre L, Rouyer C. Temporary forced laughter after unilateral strokes. Eur Neurol 1994, 34: 36-39.

[18] 18. Danek A, Bauer M, Fries W. Tracing of neural connections in the human brain by magnetic resonance imaging in vivo. Eur J Neurosci 1990, 2: 112-115.

[19] 19. Dejerine J. La paralysie pseudo-bulbaire. Journal des Practiciens 1914, 21: 406-408.

[20] 20. Dupré E, Devaux A. Rire et pleurer spasmodiques par ramollissement nucléo-capsulaire antérieur: syndrome pseudo-bulbaire par désintégration lacunaire bilatérale des putamens. Rev Neurol (Paris) 1901, 9: 919-926.

[21] 21. Féré C. Paralysie pseudo-bulbaire par lésion cérébrale bilatérale. Rev Méd (Paris) 1882, 11: 858-861.

[22] 22. Gloor P, Olivier A, Quesney LF, Andermann F, Horowitz S. The role of the limbic system in experiential phenomena of temporal lobe epilepsy. Ann Neurol 1982, 12: 129-144.

[23] 23. Geschwend J. Dissoziiertes Lachen und Weinen bei apoplektischen Insult. Fortschr Neurol Psychiat 1978, 46: 29-32.

[24] 24. Hanger HC. Emotionalism after stroke. Lancet 1993, 342: 1235-1236.

[25] 25. Helgason C, Wilbur A, Weiss A, Redmond KJ, Kingsbury NA. Acute pseudobulbar mutism due to discrete bilateral capsular infarction in the territory of the anterior choroidal artery. Brain 1988, 111: 507-524.

[26] 26. Holstege G. Descending motor pathways and the spinal motor system: limbic and non-limbic components. Progr Brain Res 1991, 87: 307-421.

[27] 27. Hopf HC, Tettenborn B, Kramer G. Pontine supranuclear facial palsy. Stroke 1990, 21: 1754-1757.

[28] 28. Huang CA, Broe G. Isolated facial palsy: a new lacunar syndrome. J Neurol Neurosurg Psychiatry 1984,47: 84-86.

[29] 29. Ironside R. Disorders of laughter due to brain lesions. Brain 1956, 79: 589-609.

[30] 30. Iwatsubo T, Kusuhara S, Kanemitsu A, Shimada H, Toyokura Y. Corticofugal projections to the motor nuclei of the brainstem and spinal cord in humans. Neurology 1990, 40: 309-312.

[31] 31. Karnosh LJ, Connor WH. Syphilitic pseudobulbar palsy with compulsive weeping. Am J Syph Gon Ven Dis 1936, 20: 115-123.

[32] 32. Langworthy OR, Hesser FH. Syndrome of pseudobulbar palsy: an anatomic and physiologic analysis. Arch Intern Med 1940, 65: 106-121.

[33] 33. Lawson IR, MacLeod RDM. The use of imipramine (Tofranil⁸) and other drugs in organic emotionalism. Br J Psychiatry 1969, 115: 281-285.

[34] 34. Lépine R. Note sur la paralysie glosso-labiée cérébrale a forme pseudo-bulbaire. Rev Mens Med Chir 1877, 1: 909-922.

[35] 35. Lépine R. Paralysie glosso-labiée cérébrale: rire et pleurer spasmodiques. Rev Méd (Paris) 1896, 16: 263-270.

[36] 36. Leys D, Lejeune JP, Bourgeois P, Blond S, Petit H. Syndrome pseudo-bulbaire aigu: infarctus bilatéral de la jonction capsule interne-corona radiata. Rev Neurol (Paris) 1985, 141: 814-818.

[37] 37. Lieberman A, Benson F. Control of emotional expression in pseudobulbar palsy. Arch Neurol 1977, 34: 717-719.

[38] 38. Magnus A. Fall von Aufhebung des Willenseinflusses auf einige Hirnnerven. Müller's Arch 1837, 258-266.

[39] 39. Mahoney FL, Barthel DW. Functional evaluation: the Barthel index. Md State Med J 1965, 14: 61-65.

[40] 40. Marie P. Des foyers de désintégration et de différents autres états cavitaires du cerveau. Rev Méd (Paris) 1901, 21: 281-298.

[41] 41. Mouton P, Rémy A, Cambon H. Rire spasmodique par lésion unilatérale du tronc cérébral. Rev Neurol (Paris) 1994, 150: 302-303.

[42] 42. Nighoghossian N, Ryvlin P, Trouillas P, Laharotte JC, Froment JC. Pontine versus capsular pure motor hemiparesis. Neurology 1993, 43: 2197-2201.

[43] 43. Poeck K. Pathological laughter and crying. In Vinken CI, Bruyn GW (eds). Handbook of Clinical Neurology, Vol 1 (45): Clinical Neuropsychology, Frederiks JAM, ed. Amsterdam: Elsevier B.V. 1985, p 219-225.

[44] 44. Poeck K, Pilleri G. Pathologisches Lachen und Weinen. Arch Neurol Psychiatr 1964, 92: 323-370.

[45] 45. Preskhorn SH. Pharmacokinetics of antidepressants: why and how they are relevant to treatment. J Clin Psychiatry 1993, 54 (Suppl 9): 14-34.

[46] 46. Ross ED, Rush AJ. Diagnosis and neuroanatomical correlates of depression in brain-damaged patients. Arch Gen Psychiatry 1981, 38: 1344-1354.

[47] 47. Schiffer RB, Cash J, Herndon RM. Treatment of emotional lability with low-dose tricyclic antidepressants. Psychosomatics 1983, 24: 1094-1096.

[48] 48. Sloan RL, Brown KW, Pentland B. Fluoxetine as a treatment for emotional lability after brain injury. Brain Inj 1992; 6: 315-319.

[49] 49. Tatemichi TK, Nichols FT, Mohr JP. Pathological crying: a pontine pseudobulbar syndrome. Ann Neurol 1987; 22: 133.

[50] 50. Udaka F, Yamao S, Nagata H, Nakamura S, Kameyama M. Pathologic laughing and crying treated with levodopa. Arch Neurol 1984, 41: 1095-1096.

[51] 51. Voogd J, Feirabend HKP, Schoen JHR. Cerebellum and precerebellar nuclei. In Paxinos G (ed). The Human Nervous System. San Diego: Academic Press, 1990, p 321-386.

[52] 52. Wali GM. "Fou rire prodromique" heralding a brainstem stroke. J Neurol Neurosurg Psychiatry 1993, 56: 209-210.

[53] 53. Wilson SAK. Some problems in neurology: II. Pathological laughing and crying. J Neurol Psychopathol 1924, 16: 299-333.

[54] 54. Yarnell PR. Pathological crying localization. Ann Neurol 1987, 22: 133-134.