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lesions in the thalamus and those extending into the midbrain can cause various movement disorders such as dystonia , asterixis , and ballism - chorea .
convulsive movements have been reported in bilateral paramedian thalamic and midbrain infarction [ 2 , 3 , 4 , 5 , 6 , 7 ] .
we here report on the case of a patient with clonic movements of both arms that were observed at the onset of infarction and offer a review of the literature .
a 71-year - old man , with a ten - year history of chronic hemodialysis due to diabetic nephropathy , was brought to the emergency room .
spontaneous symmetrical clonic movements of both arms lasting for 10 to 20 s were observed at 2-to 3-min intervals .
the results of laboratory tests on the following were normal : blood cell count , electrolyte level , glucose level , arterial blood gas , and cerebrospinal fluid .
brain magnetic resonance imaging ( mri ) showed acute bilateral paramedian thalamic and midbrain infarction ( fig .
we report on the case of a patient with clonic movements of both arms at the onset of bilateral paramedian thalamic and midbrain infarction . in the literature
[ 2 , 3 , 4 , 5 , 6 , 7 ] , convulsive movements were observed mostly at the onset of infarction .
clonic movements appear frequently in the limbs , particularly in both arms ( table 1 ) .
lesions in the thalamus and those extending into the midbrain can cause various movement disorders such as dystonia , asterixis , and ballism - chorea . the thalamus relays inputs from peripheral sensory pathways , the basal ganglia , and the cerebellum to the cerebral cortex . lesions in specific thalamic nuclei and dysfunction of the networks may contribute to these abnormal movements .
however , dystonia , asterixis , and ballism - chorea are unlikely because of the clonic nature of the movements in our patient .
although the cerebral cortex is considered important for the development of seizures in general , previous experimental studies have suggested that electrical or chemical stimulation of the brainstem tegmentum , particularly the mesencephalic reticular formation ( rf ) , induces convulsive seizures [ 9 , 10 , 11 , 12 ] .
autopsy and mri show the involvement of the midbrain tegmentum in patients with convulsive movements [ 2 , 3 , 4 , 5 , 6 , 7 ] .
however , to the best of our knowledge , such movements have never been observed in bilateral paramedian thalamic infarction without midbrain lesions .
these findings suggest that the mesencephalic rf has a crucial role in the generation of convulsive seizures in bilateral paramedian thalamic and midbrain infarction .
convulsive seizures induced by electrical stimulation of the mesencephalic rf are not eliminated by precollicular transection [ 10 , 11 ] , but pontine tegmentum lesions attenuate the convulsions of brainstem origin .
these findings suggest that the generation of the motor component in convulsive seizures is induced by the activation of the descending rf .
furthermore , seizures can take a variety of motor patterns depending on the intensity of stimulation .
a high intensity of stimulation causes tonic movements , whereas a low intensity of stimulation causes clonic movements of the forelimbs , and the subsequent increases in stimulation intensity produce a spread of clonic movements down to include the hind limbs .
it is hypothesized that the rostrocaudal spread observed in convulsions reflects the rostrocaudal spread of discharge down the polysynaptic descending pathways within the intermediate zone of the spinal gray matter .
this can explain why clonic movements were sometimes observed only in both arms , but have never been observed in the legs without the involvement of the arms in bilateral paramedian thalamic and midbrain infarction
. in summary , convulsive movements , particulary clonic movements of both arms , can develop in bilateral paramedian thalamic and midbrain infarction as an initial symptom .
physicians should recognize this condition , because not only seizure control but also early management of ischemic stroke is required .
although some previous reports have described convulsive movements in bilateral paramedian thalamic and midbrain infarction , little is known about their nature . a 71-year - old man presented with impaired consciousness and clonic movements of both arms . 
 each series of movements lasted 10 to 20 s and occurred at 2-to 3-min intervals , which disappeared after intravenous administration of diazepam and phenytoin . 
 magnetic resonance imaging showed acute bilateral paramedian thalamic and midbrain infarction . a review of the literature revealed that convulsive movements were observed mostly at the onset of infarction . 
 clonic movements appeared frequently in the limbs , particularly in both arms . 
 clinical observations and results of animal experiments suggest that these seizures might originate from the mesencephalic reticular formation . 
 physicians should recognize this condition , because not only seizure control but also early management of ischemic stroke is required .