The internal capsule (IC) is a vital brain structure housing descending and ascending fiber tracts, with traditional assumptions about the corticobulbar and corticospinal tracts descending through the genu and anterior third of the posterior limb of internal capsule (PLIC), respectively. However, observations of IC infarctions reveal that symptoms often deviate from the expected fiber pattern, prompting a deeper exploration of these complexities. The posterior limb of the IC receives its blood supply from the lenticulostriate branches of the middle cerebral artery and the anterior choroidal artery (AChA). AChA infarctions present a diverse array of symptoms beyond the classic triad, reflecting the intricate vascular supply and lesion patterns within this region. We present a case of a 74-year-old male farmer with right-hand dominance, who experienced a fall resulting in head and right lower limb injuries. Subsequently, he developed weakness in his left upper and lower limbs, facial deviation, slurred speech, and swelling in the right lower limb. Following these symptoms, his family promptly brought him to the hospital on November 30, 2023. Extensive investigations, including magnetic resonance imaging (MRI), revealed a hyper-acute infarct in the posterior limb of the left IC. The patient was admitted to the intensive care unit (ICU) for three days and later shifted to the neurology ward where medical management was commenced, including physiotherapy protocol that was started on December 2, 2023. Physiotherapy interventions were designed to address the patient\'s weakness, altered sensation, and diminished reflexes. Therapeutic goals focused on preventing complications, improving posture, enhancing range of motion (ROM), and mitigating breathing difficulties and mobility issues. The physiotherapy aimed to enhance the patient\'s overall physical and mental well-being, emphasizing independence and improved quality of life. Regular assessments and adjustments to the therapeutic interventions were made based on the patient\'s progress. This case underscores the importance of tailored physiotherapy interventions in addressing the diverse manifestations of IC infarctions, contributing to a comprehensive understanding of rehabilitation strategies in neurologically compromised individuals.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) leading to oedema, primarily in the internal capsule, are extremely rare and, to our knowledge, have never been reported. We reported a case of DAVFs with oedema in bilateral internal capsule oedema and reviewed the literature.
METHODS: The report describes a unique imaging presentation of cases of DAVFs as symmetric lesions, mainly in the bilateral internal capsule. It also reviews the literature for symmetric lesions in the internal capsule and central grey matter caused by DAVFs to further characterize this rare entity and differential diagnosis through imaging features.
RESULTS: In cases of symmetric oedema caused by DAVFs, the most common artery involved in arterial supply was the middle meningeal artery (13/24; 54%). The main vein involved in the drainage was the Galen vein (18/29; 62%). Most cases were treated with transarterial embolization (23/29; 79%), and the probability of effective treatment or complete cure is 100%. On imaging, the vasogenic oedema signal caused by DAVFs is a symmetrical lesion of the bilateral internal capsule, that is, DWI MRI shows a high signal in the unrestricted diffusion area on the apparent diffusion coefficient map.
CONCLUSIONS: MR has good diagnostic value in abnormal basal ganglia symmetric signals caused by DAVFs, and can quickly identify DAVFs early.

OBJECTIVE: Deep brain stimulation (DBS) is considered a promising intervention for treatment-resistant obsessive-compulsive disorder (OCD). The present study describes the outcomes of the first DBS procedures for OCD in Iran.
METHODS: Four women patients (age range, 25-35 years) with severe OCD meeting stringent criteria for refractoriness to treatment were selected by Psychosurgery Review Board. DBS electrodes were bilaterally implanted in the internal capsule and nucleus accumbens (NAc). Clinical and neuropsychological assessments were undertaken before and after implantation. The outcomes included Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Anxiety Rating Scale (HAM-A), neuropsychological assessments including the Wisconsin Card Sorting Test, Wechsler Memory Scale, and adverse events.
RESULTS: The baseline mean score of the Y-BOCS and HAM-A was 32 ± 6 and 23 ± 14 respectively and decreased to 26 ± 8 and 17 ± 9 after one-year implantation, showing a 19% improvement. Two patients were responders and showed a notable improvement. One patient\'s score declined 28%, who was not satisfied with DBS results, and one patient worsened under-stimulation. Improvements in the severity of anxiety and cognitive performance were consistent with OCD improvement, and the successfully treated patients showed improvement in anxiety and cognitive performance. No significant cognitive declines were seen. Two patients\' suicidal ideation appeared after DBS as an important adverse event.
CONCLUSIONS: Bilateral DBS of the internal capsule/NAc may be an effective and safe treatment for treatment-refractory OCD. However, there is a need to consider accessibility, high cost, cost-effectiveness, and standardized methodology in future research.

Deep brain stimulation (DBS) is effective for patients with treatment refractory obsessive-compulsive disorder (OCD). Autism spectrum disorder (ASD) is present in up to a third of all patients with OCD, but it is unknown whether effectiveness of DBS for OCD also applies for patients with comorbid ASD. The present case series is the first to examine effectiveness on OCD symptoms and safety of DBS in patients with OCD and ASD specifically.
Six consecutive patients with treatment-refractory OCD and comorbid ASD received DBS of the ventral anterior limb of the internal capsule (vALIC) or medial forebrain bundle (MFB). We examined effectiveness of DBS on symptoms of OCD and depression with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Hamilton Depression Rating Scale (HAM-D), respectively. We included qualitative data to describe the course of treatment in individual patients with OCD and ASD.
We found that DBS significantly decreased symptoms of OCD (p < .001) and depression (p = .007). Four out of six patients with OCD and comorbid ASD were responders (decrease ≥ 35% in Y-BOCS), one patient was partial-responder (decrease 25-35% in Y-BOCS) and one patient did not respond (decrease ≤ 25% in Y-BOCS). Serious adverse events were an infection of the DBS system, and a suicide attempt.
Though present results are preliminary, DBS reduced symptoms of OCD and depression in patients with OCD and comorbid ASD. Comorbid ASD should therefore not be seen as a contra-indication for DBS in OCD.

We present a case of a 73-year-old man who developed sudden onset dysarthria, dysphagia and bilateral facial weakness with automato-voluntary dissociation, which deteriorated rapidly to anarthria and aphonia within a few days. MRI scan of the head showed acute infarct in right internal capsule and an old infarct in the left corona radiata while the rest of the investigations were normal. Based on these findings, diagnosis was thought to be subopercular syndrome. He recovered significantly in a few weeks\' time.

BACKGROUND: Only a small proportion of schizophrenia patients present with catatonic symptoms. Imaging studies suggest that brain motor circuits are involved in the underlying pathology of catatonia. However, data about diffusivity dysregulation of these circuits in catatonic schizophrenia are scarce.
OBJECTIVE: To assess the involvement of brain motor circuits in schizophrenia patients with catatonia.
METHODS: Diffusion tensor imaging (DTI) was used to measure white matter signals in selected brain regions linked to motor circuits. Relevant DTI data of seven catatonic schizophrenia patients were compared to those of seven non-catatonic schizophrenia patients, matched for sex, age, and education level.
RESULTS: Significantly elevated fractional anisotropy values were found in the splenium of the corpus callosum, the right peduncle of the cerebellum, and the right internal capsule of the schizophrenia patients with catatonia compared to those without catatonia. This finding showed altered diffusivity in selected motor-related brain areas.
CONCLUSIONS: Catatonic schizophrenia is associated with dysregulation of the connectivity in specific motoric brain regions and corresponding circuits. Future DTI studies are needed to address the neural correlates of motor abnormalities in schizophrenia-related catatonia during the acute and remitted state of the illness to identify the specific pathophysiology of this disorder.

Objective: KMT2B-related dystonia is a progressive childhood-onset movement disorder, evolving from lower-limb focal dystonia into generalized dystonia. With increasing age, children frequently show prominent laryngeal or facial dystonia manifesting in dysarthria. Bilateral deep brain stimulation of the globus pallidus internus (GPi-DBS) is reported to be an efficient therapeutic option. Especially improvement of dystonia and regaining of independent mobility is commonly described, but detailed information about the impact of GPi-DBS on dysarthria and speech is scarce. Methods: We report the 16-months outcome after bilateral GPi-DBS in an 8-year-old child with KMT2B-related dystonia caused by a de-novo c.3043C>T (p.Arg1015*) non-sense variant with special emphasis on dysarthria and speech. We compare the outcome of our patient with 59 patients identified through a PubMed literature search. Results: A remarkable improvement of voice, articulation, respiration and prosodic characteristics was seen 16 months after GPi-DBS. The patients\' speech intelligibility improved. His speech became much more comprehensible not only for his parents, but also for others. Furthermore, his vocabulary and the possibility to express his feelings and wants expanded considerably. Conclusion: A positive outcome of GPi-DBS on speech and dysarthria is rarely described in the literature. This might be due to disease progression, non-effectiveness of DBS or due to inadvertent spreading of the electrical current to the corticobulbar tract causing stimulation induced dysarthria. This highlights the importance of optimal lead placement, the possibility of horizontal steering of the electrical field by applying directional stimulation with segmented leads as well as the use of the lowest possible effective stimulation intensity.

Agraphia is defined as the disruption of the previously intact writing skills due to an acquired brain damage. Stroke remains the most common cause of language impairment; however, writing disorders, including agraphia, are underestimated in patients with stroke. In this regard, we report two patients presenting with pure agraphia as an early symptom of stroke. Both patients complained of at least two difficulties in visualizing letter formation beforehand, the frequent need for verbal cues, misuse of lines and margins, poorly legible signature, and writing and thinking at the same time (e.g., creative thinking and taking notes). They underwent brain magnetic resonance imaging which revealed a small lacunar infarction of the left insula and external capsule (patient 1) and a small hemorrhagic lesion in the posterior limb of the left internal capsule (patient 2). To our knowledge, this is the first report on pure agraphia as the presenting symptom of stroke. We suggest that all patients with acute agraphia, even when presenting as an isolated symptom, should be evaluated for stroke, in order to better facilitate its diagnosis and treatment.

Drug addiction is one of the most prevalent and costly health problems worldwide. Over the past decade, deep brain stimulation (DBS) has increasingly been used for the treatment of drug addiction. Simultaneous DBS of nucleus accumbens (NAc) and the anterior limb of the internal capsule (ALIC) has successfully been used for preventing heroin relapse. However, the excessive energy consumption speeds up battery depletion, which puts a burden on patients. By comparison, anterior capsulotomy is usually more convenient for patients and its clinical efficacy is similar to that of ALIC DBS. Accordingly, NAc DBS combined with anterior capsulotomy may also be an effective, yet more convenient, intervention for drug addiction and relapse prevention.
The patient was a 28-year-old man with a polysubstance use disorder (bucinnazine, morphine, and hypnotics) for 13 years. After bilateral NAc DBS combined with bilateral anterior capsulotomy, his craving for the three drugs decreased markedly, and he remained abstinent throughout the follow-up period of approximately 1-year. Moreover, psychiatric and neuropsychological assessments showed significant improvements in depression, anxiety, sleep, quality of life, and most aspects of cognitive functioning. His overall health status was also improved.
NAc DBS combined with anterior capsulotomy is a promising surgical treatment for drug addiction.

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