Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal

mystery of yawning 


















mise à jour du
30 mai 2019
Dubai Medical journal
Case report
May 2019
Parakinesia Brachialis Oscitans
due to Brain Stem Infarct
Sanjith Aaron
Amal Al Hashmi
Department of Neurology, Khoula Hospital, Ministry of Health, Muscat, Oman


Tous les articles sur la parakinésie brachiale oscitante 
All articles about parakinsia brachialis oscitans 
In stroke patients, involuntary movements can occur both in the acute and chronic phase. Here, we describe one such involuntary movement consistent with the rare phenomenon of parakinesia brachialis oscitans (PBO). PBO has been reported in ischaemic and haemorrhagic strokes involving the anterior circulation; however, this is only the second time this phenomenon is being reported in posterior circulation stroke in the English literature.
Chez les patients ayant subi un AVC, des mouvements involontaires peuvent survenir tant à la phase aiguë que à la phase chronique. Les auteurs décrivent ici un de ces mouvements involontaires, compatible avec le phénomène rare de parakinesia brachialis oscitans (PBO). Des cas de PBO ont été rapportés dans des accidents vasculaires cérébraux ischémiques et hémorragiques impliquant la circulation antérieure. Cependant, ce n'est que la deuxième fois que ce phénomène est rapporté dans les accidents vasculaires cérébraux de la circulation postérieure dans la littérature anglaise.

Abnormal and often bizarre involuntary movements can occur in the acute or late setting of an ischaemic stroke. Clinicians need to be aware of these to avoid mis- diagnosis. Here, we present a rare phenomenon termed "parakinesia brachialis oscitans" (PBO) in a patient with an acute ischaemic stroke involving the brainstem.
A 53-year-old woman was admitted with a history of noticing weakness on the left side of her body after getting up from her sleep. She was a poorly controlled diabetic and hypertensive. There was no past history of stroke or transient ischaemic attacks.
On examination, she was fully conscious, orientated and obeying commands. The language functions were normal. There was no sensory, motor or visuo-spatial neglect. The cranial nerve examination showed a mild lower motor neurone type of facial weakness on the right side. The muscle tone on the left side was reduced. The power in the left upper limb was grade 1/5 and grade 0/5 in the lower limbs. The sensory examination was normal. MRI showed an acute infarct in the right pons and upper medulla with restricted diffusion on diffusion-weighted images and high signals on the T2 and T2 FLAIR images. The CT angiogram showed extensive intracranial atherosclerosis with involvement of the bilateral cavernous segments of the internal carotid arteries and the bilateral middle cerebral and anterior cerebral arteries.
She had presented outside the window period of thrombolysis and was conservatively managed. On the second day after admission, the power improved to grade 2/5 in the upper limb.
The patient also mentioned that she felt her left upper limb was lifted up whenever she yawned. On observing the patient, it was confirmed that during yawning her left upper limb was involuntarily lifted up above her head. After the cessation of yawning, the limb power returned to its earlier power of 2/5. This involuntary movement occurred every time the patient yawned. The patient's level of consciousness was preserved before, during and after these movements. There were no other concomitant movements noticed either of the face or of the lower limbs. No involuntary move- ments were seen on the stroke-unaffected right side.
These findings were consistent with the rare phenomenon of PBO, which is the involuntary movement of a paralysed upper limb induced by the act of yawning. During her hospital stay, the patient continued to improve and was able to ambulate with one person's support by 8 days. The parakinesia was observed for 3 days and had disappeared by the time of her discharge.
Yawning is a poorly understood phenomenon, which has been observed even during foetal life [1]. It is observed not only in humans but also in non-human primates and other vertebrates and usually occurs after waking up and before falling asleep. A typical yawn lasts 5 s [2] and consists of an initial reflexive wide opening of the mouth accompanied by a slow and deep inhalation through the open mouth and nose, which is followed by a slow expiration [3]. During a yawn, a reflexive retroflexion of the head and arm elevation can occur.
The neurophysiological basis of yawning is not well understood. The paraventricular nucleus (PVN) of the hypothalamus is considered as the supratentorial control centre [4]. The hypothalamus exerts its influence on the lower centres through the paraventriculo-spinal pathway. This pathway connects the PVN and other hypothalamic areas with preganglionic sympathetic and parasympathetic neurones of the dorsal vagal complex and thoracic spinal cord [5]. The lower centres for yawning include the motor nuclei of the V, VII, IX, XI and XII cranial nerves. However, there is a neocortical control mechanism on the hypothalamic PVN for helping us control yawning in socially inappropriate situations. Walusinski [6] in 2014 proposed an exciting new hypothesis, according to which yawning switches the default-mode network to the attention network by activating cerebrospinal fluid flow, thus clearing somnogens from the brain and reducing sleepiness.
Abnormal yawning can be seen in many neurological disorders. It can be a premonitory symptom in migraine; peri-ictal yawning can occur in seizures; and spontaneous yawning can be seen in persistent vegetative state, traumatic brain injury and brain tumours. Excessive yawning has been noted to occur in patients with amyotrophic lateral sclerosis (especially with bulbar-onset amyotrophic lateral sclerosis) [7].
Excessive yawning can herald a posterior circulation stroke [8]. In ischaemic anterior circulation strokes with cortical dysfunction, excessive yawning has been observed [9], and one possible explanation is that the hypothalamus is released from the neocortical control mechanism. Studies [10] have shown that involvement of the insula and caudate nucleus has the strongest correlates for causing excessive yawing in patients with anterior circulation strokes. In patients with bilateral anterior opercular syndrome (Foix-Chavany-Marie syndrome) having paralysis of the voluntary facial and pharyngeal innervation, yawning can occur despite weakness [11].
In some cases of hemiplegia, yawning can cause involuntary movement of a paralysed upper limb. This phenomenon was termed PBO [12]. It has been noted in both ischaemic and haemorrhagic strokes involving the middle cerebral artery territory, particularly the lenticulostriate branches [13]. A case of PBO in a case of right-sided pontine infarction due to basilar artery thrombosis was also noted [14].
The exact mechanism which causes this phenomenon is not clear. Walusinski et al. [15] proposed a model where the cortico-neocerebellar tract (corticospinal and corticonuclear pathways) of the extrapyramidal system is damaged, which in turn disinhibits the spino-archeocerebellar tract, enabling the lateral reticular nucleus to fire, resulting in motor stimulation of the arm.
To the best of our knowledge, this is only the second case in the English literature to report this phenomenon in a case of posterior circulation ischaemic stroke.
1 Sepulveda W, Mangiamarchi M. Fetal yawning. Ultrasound Obstet Gynecol. 1995;5(1):57&endash;9.
2 Askenasy JJ. Is yawning an arousal defense reflex? J Psychol. 1989;123(6):609&endash;21.
3 Provine RR. Yawning as a stereotyped action pattern and releasing stimulus. Ethology. 1986;72(2):109&endash;22.
4 Seki Y, Sato-Suzuki I, Kita I, Oguri M, Arita H. Yawning/cortical activation induced by microinjection of histamine into the paraventricular nucleus of the rat. Behav Brain Res. 2002;134(1-2):75&endash;82.
5 Goessler UR, Hein G, Sadick H, Maurer JT, Hörmann K, Verse T. [Physiology, role and neuropharmacology of yawning]. Laryngo-rhinootologie. 2005;84(5):345&endash;51. German.
6 Walusinski O. How yawning switches the default-mode network to the attentional network by activating the cerebrospinal fluid flow. Clin Anat. 2014;27(2):201&endash;9.
7 Wicks P. Excessive yawning is common in the bulbar-onset form of ALS. Acta Psychiatr Scand. 2007;116(1):76&endash;7.
8 Cattaneo L, Cucurachi L, Chierici E, Pavesi G. Pathological yawning as a presenting symptom of brain stem ischaemia in two patients. J Neurol Neurosurg Psychiatry. 2006;77(1):98&endash;100.
9 Singer OC, Humpich MC, Lanfermann H, Neumann-Haefelin T. Yawning in acute anterior circulation stroke. J Neurol Neurosurg Psychiatry. 2007;78(11):1253&endash;4.
10 Krestel H, Weisstanner C, Hess CW, Bassetti CL, Nirkko A, Wiest R. Insular and caudate lesions release abnormal yawning in stroke patients. Brain Struct Funct. 2015;220(2):803&endash;12.
11 Ghika J, Vingerhoets F, Bogousslavsky J. Dissociated preservation of automatic-voluntary jaw movements in a patient with biopercular and unilateral pontine infarcts. Eur Neurol. 2003;50(3):185&endash;8.
12 Walusinski O, Quoirin E, Neau JP. [Parakinesia brachialis oscitans]. Rev Neurol (Paris). 2005;161(2):193&endash;200. French.
13 Bladin PF, Berkovic SF. Striatocapsular in- farction: large infarcts in the lenticulostriate arterial territory. Neurology. 1984;34(11):1423&endash;30.
14 Töpper R, Mull M, Nacimiento W. Involun- tary stretching during yawning in patients with pyramidal tract lesions: further evidence for the existence of an independent emotion- al motor system. Eur J Neurol. 2003;10(5):495&endash;9.
15 Walusinski O, Neau JP, Bogousslavsky J. Hand up! Yawn and raise your arm. Int J Stroke. 2010;5(1):21&endash;7.