Case Report Open Access
Hemiballism-Hemichorea Following Subthalamic Nucleus Hemorrhage
Hiromi Tateno, Keisuke Suzuki*, Madoka Okamura, Hidehiro Takekawa, Takahito Nishihira, Ayaka Numao, and Koichi Hirata
Department of Neurology, Dokkyo Medical University, Japan
*Corresponding author: Keisuke Suzuki, Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan, Tel: +81-282-86-1111; Fax: +81-282-86-5884; E-mail: @
Received: October 31, 2013; Accepted: January 15, 2014; Published: January 18, 2014
Citation: Tateno H, Suzuki K, Okamura M, Takekawa H, Nishihira T, et al. (2014) Hemiballism-Hemichorea Following Subthalamic Nucleus Hemorrhage. SOJ Neurol 1(1), 2.
Keywords: Cerebral hemorrhage; Hemiballism-hemichorea; Magnetic resonance images; Subthalamic nucleus; Sudden onset
Case StudyTop
A 67-year-old man with untreated hypertension was admitted due to sudden onset involuntary movements involving the left arm and leg. Examination disclosed irregular coarse and twisting movement involving both distal and proximal muscles in the left arm and leg (Figure 1A). Magnetic resonance imaging and computed tomography of the brain revealed an acute hemorrhage in the right subthalamic nucleus (STN) (Figure 1B-D). His hemiballismus-hemichorea improved within a few days following administration of risperidone 1 mg/day. However, after admission, the patient became restless, agitated and delirious and these symptoms were resolved by administration of haloperidol 3mg/day and tiapride 50mg/day.
Figure 1: (A) The photographs of the patient showing hemiballism-hemichorea involving the left arm and leg. Coronal, (B) and sagittal, (C) T2 weighted brain magnetic resonance images show a high signal intensity lesion involving the right subthalamic nucleus. A brain computed tomography (D) Reveals a high density area in the right subthalamic nucleus.
Hemiballism-hemichorea is a rare hyperkinetic movement disorder [1], which typically ensues from a lesion of the contralateral STN. However, in the study including 21 patients with hemiballism-hemichorea, only 5 patients had STN lesions [1]. It can also be caused by lesions involving the afferent or efferent pathways of the STN, caudate, globus pallidus, corpus striatum, thalamus, insular parietal, temporal, or frontal cerebral cortex [1-4], and in non-ketotic hyperglycemia [5]. In addition, although rare, a patient presented with left-sided hemiballism with ipsilateral STN without contralateral basal ganglia lesions were reported [6]. Brain imaging findings of our patient clearly detect a small hemorrhage in the STN and support the importance of STN involvement in producing hemiballism-hemichorea. Given changes in the mental state in our patient, cortical involvement was suggested, which presumably resulted from disinhibition of the thalamocortical pathway due to diminished STN activity [7]. However, brain scintigraphy was not performed in our patient.
A sudden onset of hemiballism-hemichorea should prompt immediate brain imaging despite a paucity of neurological abnormalities.
References
  1. Dewey RB Jr, Jankovic J (1989) Hemiballism-hemichorea. Clinical and pharmacologic findings in 21 patients. Arch Neurol 46(8): 862-867.
  2. Al-Yacoub M, Friedman JH, Fernandez HH (2004) Hemiballismus from a parietal stroke in a Parkinson patient. Mov Disord 19(8): 986-988.
  3. Chung SJ, Im JH, Lee MC, Kim JS (2004) Hemichorea after stroke: clinical-radiological correlation. J Neurol 251(6): 725-729.
  4. Lee MS, Marsden CD (1994) Movement disorders following lesions of the thalamus or subthalamic region. Mov Disord 9(5): 493-507.
  5. Postuma RB, Lang AE (2003) Hemiballism: revisiting a classic disorder. Lancet Neurol 2(11): 661-668.
  6. Moersch FP, Kernohan JW (1939) Hemiballismus: a clinicopathologic study. Arch NeurPsych 41(2): 365-372.
  7. Albin RL (1995) The pathophysiology of chorea/ballism and Parkinsonism. Parkinsonism Relat Disord 1(1): 3-11.
 
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