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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.72 no.11 São Paulo Nov. 2014 

Images in Neurology

Adult-onset Alexander disease: could facial myokymia be a symptom?

Doença de Alexander de início no adulto: mioquimia facial pode ser sintoma?

Rosana Herminia Scola

Paulo J. Lorenzoni

Cláudia S. K. Kay

Lineu C. Werneck

1Serviço de Neurologia, Departamento de Clínica Médica, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil

A 24-year-old man presented with progressive cerebellar syndrome, which after six months evolved with dysphagia, dysphonia, corticospinal tract involvement and facial myokymia. Electromyography showed myokymic discharges (Figure). Brain and spinal cord magnetic resonance imaging (MRI) were suggestive of Alexander disease (AD) (Figure). Genetic analysis in GFAP gene confirmed AD (Asp360Asn).

Figure Brain and spinal cord magnetic resonance imaging studies showed: (A) infratentorial and upper cervical spinal cord atrophy (especially in medulla oblongata) with symmetrical areas of high signal on FLAIR images in the periventricular white matter of the brain hemispheres, brainstem and cerebellum; and (B) T1-weighted images following gadolinium contrast showing mild enhancement in medulla oblongata and upper cervical spinal cord (circles); and (C) Needle electromyography showed myokymic discharge characterized by groups of single or few spikes firing repetitively in a burst, recurring at intervals that are semirhythmic, in left orbicularis oris muscle (200uV/0.2seg). 

Adult-onset AD diagnoses can be strongly suggested by MRI findings1,2,3,4. Electromyography can usually revealed mild chronic neurogenic abnormalities or myoclonus rhythm in some patients1. Myokymia has not been reported associated to AD1,4. However, facial myokymia although typically a benign condition, may reflect the brainstem evolvement of the AD. Therefore, our case includes myokymia in the clinical and electrophysiological characteristics of the adult-onset AD, as well as, AD in the differential diagnosis of facial myokymia.


Gajja S. Salomons and Marjo S. van der Knaap for their collaboration in the radiological and genetic analysis.


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. Knaap MS, Naidu S, Breiter SN, Blaser S, Stroink H, Springer S et al. Alexander disease: diagnosis with MR imaging. AJNR Am J Neuroradiol. 2001;22(3):541-52. [ Links ]

. Rezende SAS, Fernandes M, Munhoz RP, Raskin S, Schelp AC, Knaap MS et al. Cerebellar ataxia as the first manifestation of Alexander's disease. Arq Neuropsiquiatr. 2012;70(5):309-10. [ Links ]

. Balbi P, Salvini S, Fundarò C, Frazzitta G, Maestri R, Mosah D et al. The clinical spectrum of late-onset Alexander disease: a systematic literature review. J Neurol. 2010;257(12):1955-62. [ Links ]

Received: June 13, 2014; Revised: July 30, 2014; Accepted: August 18, 2014

Correspondence: Rosana H. Scola; Serviço de Neurologia, Hospital de Clínicas, Universidade Federal do Paraná; Rua General Carneiro, 181 / 3° andar; 80060-900 Curitiba PR, Brasil; E-mail:

Conflict of interest: There is no conflict of interest to declare.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.