An unusual case of random fire-setting behavior associated with lacunar stroke

A case of a 47-year-old man with a sudden onset of a bizarre and random fire-setting behavior is reported. The man, who had been arrested on felony arson charges, complained of difficulties concentrating and of recent memory impairment. Axial T1-weighted magnetic resonance imaging showed a low intensity lacunar lesion in the genu and anterior limb of the left internal capsule. A neuropsychological test battery revealed lower than normal scores for executive functions, attention and memory, consistent with frontal lobe dysfunction. The recent onset of fire-setting behavior and the chronic nature of the lacunar lesion, together with an unremarkable performance on tests measuring executive functions two years prior, suggested a causal relationship between this organic brain lesion and the fire-setting behavior. The present case describes a rare and as yet unreported association between random impulse-driven fire-setting behavior and damage to the left internal capsule and suggests a disconnection of frontal lobe structures as a possible pathogenic mechanism.