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Unusual features in a case of bilateral paramedian thalamic infarction.

Sir: Bilateral paramedian thalamic infarction is a rare or at least rarely recognized cause of amnesia with abrupt onset. In a recent review of the literature 13 cases were reported.' The clinical picture consists of transient coma, amnesia, apathy and vertical gaze disturbance. A similar case, but with lack of impairment of consciousness and positive CSF findings as additional features, is presented. A 59-year-old, right-handed, highschool educated clerk was admitted in what appeared to be a confusional state. On that morning he awoke normally but neglected to go to work, mistakingly regarding the day as Saturday. Later he left home with his daughter with the intention of going fishing but seemed not to know what to do. He wandered aimlessly for more than two hours and was, finally, brought to the hospital. On admission the patient's general condition was good. His blood pressure was 140/80 mmHg. He was alert but displayed apathy with expressionless facies and was unaware of any problem. Speech appeared to be normal but was usually limited to brief answers to questioning. The prominent feature was severe memory disturbance concerning current events and, to a lesser degree, recent events. Recollection of previous material was less affected. He could read and write and was able to perform calculations but gave the date and day of the week incorrectly and had difficulty in finding his bed in the ward. The rest of the neurological examination was normal, apart from a slight limitation of upward gaze. The E.E.G. on the day of admission was normal, apart from mild slow waves with left temporal prevalence during hyperventilation. A second E.E.G. ten days later was normal. The CSF examination showed normal pressure and sugar, 0 cells and 166 mg% protein. A CT scan, two days after his admission, showed round hypodense areas in both medial thalami. The hypodense area in right thalamus was more extensive and showed luxury perfusion enhancement (fig (a)). Psychological testing 1 week after admission, on the Wechsler Adult Intelligence Scale (WAIS) showed that his verbal IQ was 97 and his performance IQ 85. He had low scores in subtests that primarily assess immediate verbal memory, visual-motor coordination and ability for synthesis and analysis in Letters