Supplementary Material for: Case Report: Treatment of akinetic mutism after unilateral anterior cerebral artery infarction with methylphenidate and levodopa/benserazide

Introduction: Akinetic mutism is a severe state of impaired volition that can result from a stroke. Its therapeutic evidence relies on single case reports that used atomoxetine or levodopa with variable latency and efficacy. Case presentation: We present the case of a 54-year-old woman who developed akinetic mutism after infarction in the territory of the right anterior cerebral artery, successfully treated with methylphenidate and levodopa/benserazide. Clinical examination showed a patient lacking any spontaneous speech and movement while opening her eyes and fixating. Suspecting akinetic mutism after a comprehensive diagnostic work-up, we started an individual therapy attempt with methylphenidate 10 mg and levodopa/benserazide 100/25 mg twice daily. Both drugs affect the dopaminergic and noradrenergic transmission in the frontal-subcortical circuit, compromised in akinetic mutism. We saw rapid and sustained improvement in her volitional actions, devoid of side effects. Finally, the patient was actively communicating and moving her limbs. Conclusion: We discuss the patient's favorable clinical course in response to the synergistic combination of methylphenidate and levodopa/benserazide, emerging as a promising treatment strategy, and provide a brief literature review of treatment options in akinetic mutism following stroke.

引言：运动不能性缄默症（akinetic mutism）是一类可由脑卒中（stroke）引发的严重意志障碍状态，目前其临床治疗相关证据均为采用阿托西汀（atomoxetine）或左旋多巴（levodopa）的单病例报告，且起效潜伏期与临床疗效均存在显著异质性。病例报告：本文报告1例54岁女性患者，因右侧大脑前动脉供血区脑梗死继发运动不能性缄默症，经哌甲酯（methylphenidate）与左旋多巴/苄丝肼（levodopa/benserazide）协同联合治疗后获得成功转归。临床查体可见患者睁眼凝视，但无任何自发言语与肢体活动。经全面诊断排查后，我们怀疑患者为运动不能性缄默症，遂启动个体化治疗尝试：予哌甲酯10mg、左旋多巴/苄丝肼100/25mg，每日2次给药。两类药物均可作用于运动不能性缄默症受累的额-皮质下环路（frontal-subcortical circuit），调节该区域的多巴胺能与去甲肾上腺素能神经传递。治疗后患者的意志性行为获得快速且持续的改善，且未出现任何不良反应。最终患者可主动进行言语交流，并能自主活动肢体。结论：本文探讨了该患者对哌甲酯与左旋多巴/苄丝肼协同联合治疗产生良好临床应答的完整病程，该方案有望成为脑卒中后运动不能性缄默症的潜在治疗策略，并对脑卒中后运动不能性缄默症的治疗方案进行了简要文献综述。