Successful treatment of hemiballismus with progabide, a new GABA-mimetic agent

Hemiballismus

Hemiballismus is the most dramatic movement disorder seen in clinical practice. Its emergence points to a structural lesion or metabolic dysfunction in the region of the subthalamic nucleus, its afferent or efferent pathways, or interconnected deep brain nuclei, usually on the side contralateral to the movements. Any focal process may be to blame, but elderly sufferers generally have had vascular events, whereas the etiology is infectious or inflammatory in younger patients. Severe nonketotic hyperglycemia is another important cause of hemiballismus in the elderly. Hemiballismus patients require treatment both for the underlying etiology of the movement and for the movements themselves. There are no large controlled clinical trials to guide anti-ballismus therapy. However, dopamine receptor blocking agents have an established track record in suppressing choreic and ballistic movements, and are first-line agents for acute treatment. Standard neuroleptics such as haloperidol and perphenazine are started at low doses and titrated as tolerated until the movements are controlled. Atypical antipsychotics such as risperidone and clozapine have been used in small series and may have a reduced risk of extrapyramidal side effects. Catecholamine-depleting agents such as reserpine and tetrabenazine may be considered when long-term therapy is required. Other pharmacologic agents have met with varying success. The course of hemiballismus may be complicated by exhaustion, injury, or metabolic disorders, but with good supportive care, acute survival is good, and long-term survival reflects the prognosis of the underlying etiology. In time, the ballistic movements themselves tend to subside allowing withdrawal of drugs in many cases. When movements persist, stereotactic functional neurosurgical procedures may be considered in good surgical candidates.

Olanzapine for the treatment of hemiballismus: A case report

Hemiballismus is a rare movement disorder characterized by involuntary, large amplitude movements of the limbs of 1 side of the body. We describe the case of a man in his late sixties with slurred speech, agitation, and right-sided hemiballismus resulting from a left thalamic hemorrhagic stroke. Treatment with haloperidol was unsuccessful, but both the hemiballismus and agitation diminished significantly after initiation of olanzapine (Zyprexa). The improvement in the hemiballismus was quantified by recording the number of hemiballistic movements that occurred while the patient performed standardized 30-minute sessions (daily for 5d). With the first task (reaching within the base of support while seated), the average number of hemiballismic movements per session decreased from a baseline of 23.5 to 3.0 in the upper extremity and from 20.5 to 7.0 in the lower extremity. With the second task (catching a ball while seated), the abnormal movements decreased from 52 to 6.3 in the upper extremity and from 34.5 to 2.7 in the lower extremity. This case suggests that olanzapine may be a valuable pharmacologic alternative for patients with hemiballismus.

Hemiballismus

Hemiballismus is a rare movement disorder that can be life threatening in the absence of a rational treatment approach. The pathologic abnormality lies in the subthalamic nucleus and its afferent or efferent connections. Before the advent of effective pharmacologic treatments, patients with hemiballismus had a dismal prognosis, with physical exhaustion, injuries, and medical complications often leading to death. Advances in pharmacologic management and emphasis on supportive measures have improved the outlook for these patients, with most now surviving. Hemiballismus tends to diminish or resolve spontaneously over several months. Treatment approaches should be vigorous during the acute phase but often may be discontinued after 6 months to 1 year. Surgical treatment of hemiballismus appears promising and should be reserved for the patient with persistent movements whose disease is refractory to medical management.

Hemiballismus following closed head injury

Movement disorders are relatively rare after closed head injury (CHI), but when present they can go unrecognized if clinicians are not aware of their occurrence. We are presenting a case of hemiballismus which was not recognized over 3 years and was labelled as malingering or as psychosomatic. The symptoms have responded significantly to pharmacological interventions. The SPECT scan of the brain showed the lesions in the subthalamic areas while MRI, CT scans of brain and EEGs were reported normal. It is concluded that one should be aware of the existence of movement disorders after mild to moderate CHI, and that SPECT scan of the brain should be considered if a patient is symptomatic and other neuroimaging studies prove 'normal'.

Spontaneous hemiballism and disappearance of parksinsonism following contralateral lenticular lacunar infarct

Hemiballism was observed in a 77-year-old woman with Parksinson disease after a contralateral lenticular infarct without apparent involvement of the subthalamic nucleus. Parkinsonian signs ipsilateral to the hemiballism remained abolished despite subsequent nearly complete recovery from the hyperkinesias. It is argued that clinical events were due to a single ischemic lesion of the putamen-pallidum complex.

Unilateral involuntary movements of acute onset in the adult, nine case reports and an alternative pathophysiological hypothesis

During the last decade nine adult patients were seen with an unilateral choreoathetosis or choreoballism of acute onset. In seven a hemodynamically significant lesion in a carotid artery has been detected; in four the artery was completely occluded. In one there was a subclavian steal syndrome, and in another the etiology remained unclear. Three patients had their dyskinesia at the same side as the carotid artery lesion, and four at the controlateral side.