Both anosognosia and secondary mania are associated with right hemispheric lesions. These two non-dominant syndromes, however, are rarely described as occurring together. We present a patient with a right thalamic haemorrhage giving rise to profound denial of hemiplegia and elated mood. This case suggests mechanisms for the common production of mania and anosognosia.

A 53 year old, right handed, black man, with a history of alcohol misuse and dependence and untreated hypertension, was brought to the emergency room a few hours after developing an intense headache and left sided numbness and weakness.

On admission he was described as “belligerent,” “agitated,” and “confused.” Blood pressure was 240/160. Neurological examination disclosed left lower facial droop, decreased left corneal and gag reflexes, and left hemiparesis with dense sensory deficits. With increasing obtundation, the patient was transferred to the intensive care unit and intubated. Brain MRI showed a large, right sided, hyperacute thalamic bleed with mass effect and oedema. The patient was extubated 2 days later and 4 days after the stroke he was described as being drowsy and inattentive, but was able to answer questions appropriately. Neurological examination showed contralateral gaze preference, supranuclear vertical gaze palsy, difficulty converging, left sided flaccid hemiparesis, and dense, left sided hemianaesthesia. Deep tendon reflexes were absent on the left and Babinski's reflex was present on the left. In addition, visual extinction and neglect were present.

At the time of onset of right sided weakness the patient insisted that he was “fine,” and an ambulance was called over his objections. After being extubated, the patient acknowledged that he had had a stroke, but, despite his hemiparesis, insisted that he was ready to go home and go back to work. His belief in his ability to walk led …