Abstract
BackgroundPathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of “dacrystic” epilepsy. The case reported here suggests that thalamic lesions may also cause crying spells, under the special circumstances described below.Case presentationAfter a mild left thalamic stroke a caucasian 77 years old man presented with crying spells with no emotional counterpart, triggered by thumb-index rubbing of his right hand. Only a modest sensation loss on right infra-orbital and nose-labial areas and the first three right fingers could be detected at clinical examination. The circumstances and processes leading to the crying spells were investigated, together with their neural substrate. Brain computerized tomography (CT), magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) were conducted. Neurophysiologic studies included Video-Electroencephalography, Electromyography, motor and sensory Evoked potentials. Active thumb-index rubbing, passive fingertips stimulation and interaction of sensory-motor stimulation with cognitive/speech activities were tested under different paradigms. A treatment with pregabalin (75 mg twice a day) was attempted. CT and MRI showed a small ischemic infarct in the left ventral postero-lateral thalamus, while fMRI led to the expected findings, i.e. a bilateral activation of the hand motor representation during the crying-triggering right-hand finger rubbing activity. Sensory potentials evoked from stimulation of the right upper limb were the only abnormal neurophysiologic test. Crying spells could be invariably evoked by both real and imagined active finger rubbing, in either the left of right hemi-space. Rubbing by an examiner was ineffective. Immersion in water (18 °C) but not oiling of the fingertips prevented the symptom. Administration and discontinuation of pregabalin 75 mg daily could be associated with suppression and reappearance of the symptom, respectively.ConclusionsIn this patient loss of sensation seemed to generate crying spells rather than the more common allodynia. As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the VPLT, which is linked to the anterior cingulate (limbic) cortex engaged in emotional behaviour.
Highlights
Pathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of “dacrystic” epilepsy
As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the ventral-posterior lateral thalamus (VPLT), which is linked to the anterior cingulate cortex engaged in emotional behaviour
The case is presented here of a man suffering from disabling crying spells after a mild thalamic stroke
Summary
An ischemic lesion of the VPLT was the only one visible brain alteration that could be related to patient’s symptoms. While allodynia is a component of the PSTP syndrome, yet it belongs to the large family of neuropathic pain symptoms and is not necessarily associated with thalamic lesions It may follow pure sensory loss and it is considered to reflect central “sensitization” stemming from a slow maladaptive plasticity [7, 9]. A disinhibition of the thalamo-limbic pathways remains a plausible-unproven-explanation for the phenomenon In this case the lesion might have been moderate enough to make the limbic activation undetectable at fMRI and the crying spell to require the simultaneous double triggering of the limbic areas, i.e. from peripheral stimuli causing hyperexcitation of the (already dishinibited) medial thalamic circuits, like in allodynia, and from direct central hyperexcitation of the limbic cortex caused by a frustrated sense of agency, like in other pain syndromes.
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