Long-term prognosis of vascular hemiballismus

Hemichorea associated with ipsilateral basal ganglia lesions

BACKGROUND

Hemichorea-hemiballism (HCHB) is a rare movement disorder typically associated with contralateral subthalamic nucleus (STN) lesions, but it may also occur ipsilaterally. This case report highlights a rare instance of ipsilateral HCHB caused by a putaminal hematoma, providing insights into its pathophysiology and management.

CASE REPORT

A 52-year-old female with a history of bioprosthetic valve replacement and hypertension presented with involuntary movements in the left arm. Neurological examination revealed choreiform movements in the right upper extremity and left hemihypoesthesia. Cranial CT showed a right putaminal hematoma, while MRI revealed no additional findings. Despite no response to a 7-day course of haloperidol, the patient showed significant improvement with risperidone treatment, achieving complete resolution of symptoms within five months.

CONCLUSION

HCHB is commonly associated with contralateral basal ganglia lesions; however, this case demonstrates its occurrence ipsilaterally, likely due to vascular disinhibition of basal ganglia structures. Antidopaminergic therapy, including risperidone, proved effective in managing the disorder. This report underscores the importance of recognizing ipsilateral HCHB as a rare but treatable clinical presentation.

Frequency, phenotypes, and neuroimaging of early post stroke movement disorders: a prospective study

Background

A prospective observational study recruited patients with acute stroke. Patients were assessed for the presence of post-stroke movement disorders PSMDs during the first week of stroke. This study aimed to identify the frequency, clinical characteristics, and neuroimaging of early PSMDs (within the first week) and followed for 1 year.

Results

A total of 600 patients were recruited; 21 patients (3.5%) with PSMDs were detected. Thirteen (2.2%) patients presented with intention tremor/ataxia and eight (1.3%) presented with other movement disorders (most commonly, chorea and tremor). One patient presented with periodic left upper limb shaking with right subcortical watershed infarction, and one patient developed palatal myoclonus with right middle cerebral artery infarction. Patients with PSMDs had significantly lower stroke severity (NIHSS) and were more likely to have lacunar strokes (p < 0.001 and < 0.006, respectively) than patients without PSMDs. Early PSMDs were more associated with posterior circulation strokes (84.25%).

Conclusions

Early PSMDs are commonly hyperkinetic, more associated with small vessel disease, and less severe and posterior circulation strokes, implying their clinical importance for the proper management of stroke patients.

Late-onset, first-ever involuntary movement after successful surgical revascularization for pediatric moyamoya disease - Report of two cases

Background

A small number of children with Moyamoya disease develop involuntary movements as an initial presentation at the onset, which usually resolves after effective surgical revascularization. However, involuntary movements that did not occur at the onset first occur after surgery in very rare cases. In this report, we describe two pediatric cases that developed involuntary movements during the stable postoperative period after successful surgical revascularization.

Case Description

A 10-year-old boy developed an ischemic stroke and successfully underwent combined bypass surgery. However, he developed chorea six months later. Another 8-year-old boy developed a transient ischemic attack and successfully underwent combined bypass surgery. However, he developed chorea three years later. In both cases, temporary use of haloperidol was quite effective in resolving the symptoms, and involuntary movements did not recur without any medication during follow-up periods of up to 10 years.

Conclusion

Postoperative first-ever involuntary movement is very rare in pediatric moyamoya disease, and the underlying mechanisms are still unclear, but a temporary, reversible imbalance of excitatory and inhibitory circuits in the basal ganglia may trigger the occurrence of these rare symptoms. Careful follow-up would be mandatory.

Investigation of the factors associated with hemichorea/hemiballismus in post-stroke patients

Classical knowledge highlights the role of lesions of the subthalamic nuclei (STN) in the pathophysiology of hemichorea/hemiballismus (HH). However, the published reports indicate various other lesion regions in the majority of post-stroke cases with HH. Ergo, we aimed to investigate the significance of the lesion site and clinical features for developing HH in post-stroke patients. Overall, we retrospectively scanned all the patients with stroke who were hospitalized between 01/06/2022 and 31/07/2022 in our neurology clinic. The data regarding the demographic features, comorbidities, stroke etiologies, and laboratory findings, including serum glucose and HBA1C were retrospectively recruited using the electronic-based medical record system. The cranial magnetic resonance imaging (MRI) and computed tomography images have been systematically evaluated for the presence of lesions in localizations that are previously associated with HH. We conducted comparative analyses between patients with and without HH to reveal the discrepancies between groups. The logistic regression analyses were also performed to reveal the predictive values of some features. Overall, the data of 124 post-stroke patients were analyzed. The mean age was 67.9 ± 12.4 years (F/M = 57/67). Six patients were determined to develop HH. The comparative analyses between patients with and without HH revealed that the mean age tended to be higher in the HH group (p = 0.08) and caudate nucleus involvement was more common in the HH group (p = 0.005). Besides cortical involvement was absent in all subjects developing HH. The logistic regression model revealed the presence of a caudate lesion and advanced age as factors associated with HH. We found that the caudate lesion was a crucial determinant of the occurrence of HH in post-stroke patients. With the significance of the other factors of increased age and cortical sparring, we observed differences in the HH group may be investigated also in future-related studies on larger groups.

Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management

Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.

Haemiballism/haemichorea: an atypical presentation of ischaemic stroke

A 76-year-old man was admitted to the hospital with acute onset of involuntary movements of the left side of his body. His neurological examination revealed he was oriented only to himself, and aforementioned movements of his left arm and leg. CT head demonstrated old infarcts in his right aspect of his pons and basal ganglia. Cerebrospinal fluid analysis was unremarkable. He initially had a normal blood glucose with an elevated anion gap and elevated creatine kinase. Brain MRI showed a small lacunar-type ischaemic infarct within the anteromedial aspect of the right cerebral peduncle, which localised to his haemiballism. To prevent worsening rhabdomyolysis associated with his haemiballism, the primary team initiated both tetrabenazine and diazepam. His movements improved after 1 week of medication therapy. This report discusses a thorough workup for this movement disorder and when to intervene for this distressing condition.

Management of Severe Hemiballismus: Treatment Challenges in the Acute Inpatient Rehabilitation Setting: A Case Presentation

We report a case of a patient with profound right-sided hemiballismus resulting from an acute unilateral left thalamic lesion. The hemiballismus was significant and persistent, resulting in profound functional disability. We discuss the use of low-dose haloperidol in conjunction with acute rehabilitation in the treatment of hemiballismus, resulting in decreased amplitude and frequency of adventitious movements and leading to substantial functional gains in our patient. To our knowledge, this is the first extensive report of successful rehabilitation of a patient with functionally disabling hemiballismus.

LEVEL OF EVIDENCE

V.

Post-stroke dyskinesias

Strokes, whether ischemic or hemorrhagic, are among the most common causes of secondary movement disorders in elderly patients. Stroke-related (vascular) movement disorders, however, are uncommon complications of this relatively common disease. The spectrum of post-stroke movement disorders is broad and includes both hypo- and hyperkinetic syndromes. Post-stroke dyskinesias are involuntary hyperkinetic movements arising from cerebrovascular insults and often present with mixed phenotypes of hyperkinesia which can sometimes be difficult to classify. Nevertheless, identification of the most relevant motor phenotype, whenever possible, allows for a more specific phenomenological categorization of the dyskinesia and thus helps guide its treatment. Fortunately, post-stroke dyskinesias are usually self-limiting and resolve within 6 to 12 months of onset, but a short-term pharmacotherapy might sometimes be required for symptom control. Functional neurosurgical interventions targeting the motor thalamus or globus pallidus interna might be considered for patients with severe, disabling, and persistent dyskinesias (arbitrarily defined as duration longer than 12 months).

Hemiballism with leg predominance caused by contralateral subthalamic haemorrhage

Hemiballism is a rare movement disorder characterised by high-amplitude movements of the limbs on one side of the body. Stroke of the contralateral basal ganglia, especially the subthalamic nucleus (STN) is the most common aetiology of acute development of hemiballism. Recently, the pathophysiology of hemiballism has been associated with abnormal firing patterns in the globus pallidus interna, with intermittent firing bursts followed by pauses, during which movements occur. An 87-year-old woman presented with a 5-day history of hemiballism predominantly in her leg. On the basis of her brain MRI findings, she was diagnosed as having vascular hemiballism caused by haemorrhage in the contralateral STN. Treatment with risperidone led to the clinical resolution of her condition. We discuss the distribution of the patient's ballistic movements on the basis of the somatotopic organisation of the STN.

Treatment of movement disorder emergencies

Movement disorder emergencies are defined as clinical scenarios where a movement disorder develops over hours to days, and in which morbidity and even mortality can result from failure to appropriately diagnose and manage the patient. The last decade has seen increasing recognition of various movement disorder emergencies, including acute parkinsonism, neuroleptic malignant syndrome, respiratory compromise in multiple system atrophy, dystonic storm, oculogyric crisis, and hemiballism, among others. This article will review the major movement disorder emergencies encountered in the hospital and office, emphasizing practical management and treatment.

Subthalamotomy in the treatment of Parkinson's disease: clinical aspects and mechanisms of action

Parkinson's disease (PD) is a neurodegenerative condition that can be pharmacologically treated with levodopa. However, important motor and nonmotor symptoms appear with its long-term use. The subthalamic nucleus (STN) is known to be involved in the pathophysiology of PD and to contribute to levodopa-induced complications. Surgery is considered in patients who have advanced PD that is refractory to pharmacotherapy and who display disabling dyskinesia. Deep brain stimulation of the STN is currently the main surgical procedure for PD, but lesioning is still performed. This review covers the clinical aspects and complications of subthalamotomy as one of the lesion-based options for PD patients with levodopa-induced dyskinesias. Moreover, the authors discuss the possible effects of subthalamic lesioning.

Cortical hemichorea-hemiballism

Hemichorea-hemiballism (HCHB) was infrequently related to cortical lesions such as tumor or infarction. Although functional derangement of the basal ganglia (BG) or the thalamus (Th) was suggested, pathomechanism of HCHB secondary to cortical lesions remains uncertain. We recruited the patients with HCHB secondary to cerebrovascular diseases, excluding other causes such as hyperglycemia. All the patients were studied with brain magnetic resonance imaging/angiography (MRI/MRA) and single-photon emission computed tomography (SPECT). Those with only cortical abnormalities in neuroimaging studies were sorted out as the cases of cortical HCHB. Statistical parametric mapping (SPM) analysis of SPECT was performed to investigate the pathomechanism of cortical HCHB. Ten patients (three males and seven females) were included in our study. Six patients had acute BG lesions with SPECT abnormalities, and one had old BG lesions with abnormal SPECT. Three patients were classified as cortical HCHB with lesions only in the frontal and parietal cortices in MRI and SPECT. SPM analysis revealed additional hypoperfusion in frontal areas, leaving BG and Th free of any perfusion abnormalities. Although cortical HCHB was strictly defined by MRI and SPECT, cortical HCHB was not uncommon (30 %). Further analysis showed intertwined networks among the frontal and parietal lobes for cortical HCHB. Cortical dysfunction is important in the pathogenesis of cortical HCHB even without significant involvement of BG and Th.

Movement disorders in cerebrovascular disease

Movement disorders can occur as primary (idiopathic) or genetic disease, as a manifestation of an underlying neurodegenerative disorder, or secondary to a wide range of neurological or systemic diseases. Cerebrovascular diseases represent up to 22% of secondary movement disorders, and involuntary movements develop after 1-4% of strokes. Post-stroke movement disorders can manifest in parkinsonism or a wide range of hyperkinetic movement disorders including chorea, ballism, athetosis, dystonia, tremor, myoclonus, stereotypies, and akathisia. Some of these disorders occur immediately after acute stroke, whereas others can develop later, and yet others represent delayed-onset progressive movement disorders. These movement disorders have been encountered in patients with ischaemic and haemorrhagic strokes, subarachnoid haemorrhage, cerebrovascular malformations, and dural arteriovenous fistula affecting the basal ganglia, their connections, or both.

Post-stroke Movement Disorders: Clinical Manifestations and Pharmacological Management

Involuntary abnormal movements have been reported after ischaemic and haemorrhagic stroke. Post stroke movement disorders can appear as acute or delayed sequel. At the moment, for many of these disorders the knowledge of pharmacological treatment is still inadequate. Dopaminergic and GABAergic systems may be mainly involved in post-stroke movement disorders. This article provides a review on drugs commonly used in post-stroke movement disorders, given that some post-stroke movement disorders have shown a partial benefit with pharmacological approach.

Movement disorders after stroke in adults: a review

Background

Movement disorders occur in association with stroke and may have important clinical implications.

Methods

We reviewed the medical literature regarding the clinical phenomenology, prevalence, localization and etiologic implications, and treatments for movement disorders occurring after stroke in adult patients.

Results

Movement disorders occur uncommonly after stroke and include both hyperkinetic and parkinsonian conditions. They can occur at the time of stroke or appear as a later manifestation. Stroke lesions are typically due to small vessel cerebrovascular disease in the middle or posterior cerebral artery territory, vessels supplying the basal ganglia. Hemorrhagic lesions are more likely to induce hyperkinetic movements. Movement disorders in the setting of stroke tend to resolve spontaneously over time. Medical and surgical therapies are available to treat the movement problems.

Discussion

Movement disorders after stroke can be helpful in localizing lesions after stroke, determining the etiology of stroke, may need to be a target for therapy and may importantly influence long term outcome.

Hemiballismus: current concepts and review

Hemiballism is a rare movement disorder characterized by a high amplitude movement of an entire limb or limbs on one side of the body. The acute development of hemiballismus is often caused by focal lesions in the contralateral basal ganglia and STN. Many etiologies exist for this rare disorder with vascular causes and nonketotic hyperglycemia being the most common. Clearer understanding of the pathophysiology of hemiballism has led to important insights into the function and interaction of structures within the basal ganglia. Newer models of basal ganglia function have been proposed based on the study of the pathophysiology of hemiballism. Prognosis is favorable for most patients with complete resolution with or without treatment. Medical and surgical treatments are often successful in reducing or completely ameliorating the movements in those patients with more severe movements.

Pathological basal ganglia activity in movement disorders

Our understanding of the pathophysiology of movement disorders and associated changes in basal ganglia activities has significantly changed during the last few decades. This process began with the development of detailed anatomical models of the basal ganglia, followed by studies of basal ganglia activity patterns in animal models of common movement disorders and electrophysiological recordings in movement disorder patients undergoing functional neurosurgical procedures. These investigations first resulted in an appreciation of global activity changes in the basal ganglia in parkinsonism and other disorders, and later in the detailed description of pathological basal ganglia activity patterns, specifically burst patterns and oscillatory synchronous discharge of basal ganglia neurons. In this review, we critically summarize our current knowledge of the pathological discharge patterns of basal ganglia neurons in Parkinson's disease, dystonia, and dyskinesias.

Hemiballismus

Hemiballism is a relatively rare hyperkinetic movement disorder characterized by involuntary, violent, coarse and wide-amplitude movements involving ipsilateral arm and leg. Although classically related to lesions in the subthalamic nucleus, in clinical-radiological series of hemiballism most patients had lesions outside this nucleus, involving mainly other basal ganglia structures. It has been suggested that abnormal neuronal firing patterns in the internal segment of the globus pallidus may be related to the pathogenesis of hemiballism. Stroke is the most common cause, but in recent years an increasing number of patients with hemiballism associated with nonketotic hyperglycemia or with complications of human immunodeficiency virus (HIV) infection have been reported. Contrarily to what was stated in older literature, hemiballism has, in general, a relatively good prognosis. Depending on the underlying causes, many patients may experience spontaneous improvements or remissions. Treatment should be directed to the cause of hemiballism. Symptomatic treatment includes the use of drugs, particularly blockers of striatal D2 dopamine receptors and tetrabenazine. Surgical treatment, especially pallidotomy, is a therapeutic option for the minority of patients with severe persistent disabling hemiballism.

Vascular chorea in adults and children

Chorea may occur as part of the symptomatology of acute stroke; it occasionally also may be delayed or progressive. Patients with vascular-related chorea typically present with an acute or subacute onset of chorea of one side of the body (hemichorea), contralateral to the lesion. Cerebrovascular disease is the most common cause of sporadic chorea. Lesions are most frequently found in the thalamus and lentiform nucleus, and less often in subthalamic nucleus. The differential diagnosis of choreic syndromes relies not so much on differences in the phenomenology of the hyperkinesia but the age at onset, mode of onset, time course, family history, drug use, distribution of chorea in the body, and presence of accompanying neurological findings. Magnetic resonance imaging is preferred to demonstrate the presence of strategic small lesions in regions that are difficult to image with computed tomography, such as the globus pallidus, thalamus, and subthalamic nucleus. Although the prognosis of hemichorea can be benign, the long-term prognosis is not specifically determined by the hemichorea but by the long-term prognosis of stroke patients. Symptomatic treatment with antichoreic drugs may be necessary in the acute phase. Surgery is rarely indicated to treat vascular chorea.

Movement disorders after stroke

Many different types of hyperkinetic and hypokinetic movement disorders have been reported after ischaemic and haemorrhagic stroke. We searched the Medline database from 1966 to February 2008, retrieving 2942 articles from which 156 relevant case reports, case series and review articles were identified. The papers were then further reviewed and filtered and secondary references found. Here we review the different types of abnormal movements reported with anatomical correlation, epidemiology, treatment and prognosis. Post stroke movement disorders can present acutely or as a delayed sequel. They can be hyperkinetic (most commonly hemichorea-hemiballism) or hypokinetic (most commonly vascular parkinsonism). Most are caused by lesions in the basal ganglia or thalamus but can occur with strokes at many different locations in the motor circuit. Many are self limiting but treatment may be required for symptom control.

Chapter 33: the history of movement disorders

Role of basal ganglia: Vesalius and Piccolomini distinguished subcortical nuclei from cortex and white matter in the 16th century. Willis' mistaken concept in the late 17th century that the corpus striatum was the seat of motor power persisted for 200 years and formed the basis of mid-19th-century localizations of movement disorders to the striatum (chorea by Broadbent and Jackson, and athetosis by Hammond). By the late 19th century, many movement disorders were described but for most no pathologic correlate was known. Tremor: Descriptions of tremors progressed from Galen's definition in the 2nd century; to Galileo's physiologic tremor in 1610; separation of involuntary movements during action and at rest in the 17th and 18th centuries by de la Boë Sylvius and van Sweiten; description of Parkinson's disease by Parkinson, discrimination of the rest tremor of Parkinson's disease from the intention tremor of multiple sclerosis by Charcot, and recognition of familial action tremors by Dana and others in the late 19th century; and recognition of autosomal dominant essential tremor in the mid-20th century. Parkinsonism: Pathologic changes in Parkinson's disease were recognized in the substantia nigra by Blocq and Marinescu in the late 19th century, and around 1920 Trértiakoff established Lewy bodies in the substantia nigra as a pathologic hallmark while the Vogts instead emphasized pathologic changes in the striatum; it was only in the mid-1960s that a nigrostriatal dopaminergic pathway was demonstrated and found to be critical to pathogenesis. Early treatment approaches with anticholinergic medications or crude neurosurgical ablation procedures were eclipsed in the 1960s by the advent of L-DOPA therapy due to the work of Carlsson and colleagues, Birkmayer and Hornykiewicz, Barbeau, and Cotzias. Later progress in understanding and treating Parkinson's disease included recognition of neuroleptic-induced parkinsonism beginning in the 1950s, development of dopamine agonists and elaboration of different dopamine receptors beginning in the 1960s, recognition of MPTP-induced parkinsonism in 1982 and subsequent development of experimental models of MPTP-induced parkinsonism. Since the 1980s, stereotactic neurosurgical ablation procedures such as stereotactic pallidotomy were revisited and improved, and stimulation or ablation procedures that modulate subthalamic nucleus activity were developed. Since 1990, rare genetic forms of Parkinson's disease were discovered, which accelerated progress in understanding pathogenesis, and established roles for alpha synuclein and the ubiquitin-proteasome proteolytic system. Separation of atypical forms of parkinsonism (e.g. Wilson's disease, multisystem atrophy, progressive supranuclear palsy, and corticobasal degeneration) from Parkinson's disease in the 20th century also led to important discoveries of basal ganglia function, and in the case of Wilson's disease to recognition of genetic mutations and effective treatments. Choreoathetosis: Since the middle ages, the term chorea has been used to describe both organic and psychological disorders of motor control. Paracelcus introduced the concept of chorea as an organic medical condition in the 16th century. Sydenham's description of childhood chorea (1686) was followed by recognition in the 19th and 20th centuries that Sydenham's chorea was a manifestation of rheumatic fever; by the 1930s, rheumatic fever was recognized as a sequel of group A streptococcal pharyngitis, which could be effectively prevented with sulfonamides. Athetosis was described by Hammond (1871) and later linked by him to a malignant growth in the contralateral corpus striatum; nevertheless, athetosis has been controversial and often dismissed as a form of post-hemiplegic chorea or part of a continuum between chorea and dystonia. Huntington's classic description of adult-onset hereditary chorea (1872) was followed a century later by demonstration that Huntington's disease is caused by an unstable CAG trinucleotide repeat expansion in the Huntington disease gene on chromosome 4; this triggered a surge in research, development of various animal models, and numerous important discoveries of cell function and disease pathogenesis. Hemiballismus and the subthalamic nucleus: The relationship between a lesion of the subthalamic nucleus of Luys and contralateral hemiballismus was first convincingly demonstrated by Martin in 1927; this led 20 years later to development of an animal model by Whittier and Mettler, who produced experimental hemichorea-hemiballismus in monkeys by lesioning the contralateral subthalamic nucleus. Since the late 1980s, the neurochemistry and neurophysiology of the subthalamic nucleus have been substantially revised with the demonstration that the subthalamic nucleus is not fundamentally inhibitory but instead provides excitatory glutaminergic inputs to the globus pallidus, and appreciation that the subthalamic nucleus serves an important role in both hyperkinetic and hypokinetic movement disorders. Dystonia: Dystonias were often interpreted in psychological or psychiatric terms since the original descriptions of generalized dystonia by Barraquer Roviralta (1897), and familial forms of generalized primary tortion dystonia by Schwalbe (1908) and Oppenheim (1911). Although Oppenheim had first insisted that dystonia was an organic disease, it was only in the late-20th century that an organic framework was firmly established with the identification of genetic mutations in some families with dystonia and with the demonstration that the basal ganglia were often damaged contralateral to acquired hemidystonia. Focal and segmental forms of dystonia, including writer's cramp, other occupational dystonias, and torticollis, were also recognized in the 19th century. Writer's cramp was clearly described in the 1830s by Bell and Kopp, and increasingly recognized in the late 19th century due in part to Solly's influential lectures on "scriviner's palsy" in the 1860s, and to increasing prevalence because of the increase in writing using primitive writing instruments. Myoclonus: In 1903, Lundborg proposed a classification of myoclonus that remains in use, with primary (essential), epileptic, and secondary or symptomatic categories: essential myoclonus was described by Friedrich in 1881; forms of myoclonic epilepsy were described beginning in the late 19th century by West (1861), Unverricht (1891), and Lundberg (1903); and secondary multifocal myoclonus was recognized in a wide variety of disorders beginning in the 1920s. Asterixis was described in patients with hepatic encephalopathy by Adams and Foley in 1949 and found to result from electrically silent pauses in muscle activity, which led to the concept of negative myoclonus in the 1980s. Posthypoxic action myoclonus (Lance-Adams syndrome) was described by Lance and Adams in 1963 and found to incorporate both positive and negative components. Startle syndromes: Early descriptions of pathologic startle syndromes included Beard's description of the jumping Frenchmen of Maine (1878) and Hammond's description of miryachit (1884), both of which may have had psychological origins. In contrast, hyperekplexia or "startle disease" was described in the late 1950s and early 1960s, and genetic forms were later found to result from various mutations affecting glycinergic synapses. Tics: Tic disorders were described by Itard (1825) and Trousseau (1873), but only gained wider recognition in the late 19th century after Charcot presented cases before his classroom audiences and after Gilles de la Tourette's classic description in 1885. Gilles de la Tourette and Charcot initially considered tic disorders and startle syndromes to be similar if not identical, but these disorders were later recognized as distinct. Psychodynamic and psychological theories or etiology gave way in the 1960s to biological theories supporting an important role for dopamine in pathogenesis, particularly with the discovery that neuroleptic medications could be useful in treatment.

CONCLUSION

In the last two centuries, neuroscientists and clinicians contributed greatly to our understanding of basal ganglia anatomy and physiology, as well as to movement disorder semiology, pathophysiology, treatment, and prevention. The development of animal models, and the increasing use of genetic and molecular biological techniques will lead to further advances in the coming years.

[Vascular hemiballismus due to extraluysian lesions]

INTRODUCTION

Hemiballismus is a very rare disorder; less than 7% of all hyperkinetic disorders. Classically, a lesion of the contralateral corpus Luysii is involved. We report a case of hemiballismus due to an extraluysian lesions and discuss the underlying pathophysiology.

CASE REPORT

A 74-year-old women, with a history of diabetes and hypertension, developed left-sided hemiballismus one week before admission. The brain MRI showed a right lenticular nucleus hematoma with vascular leucoencephalopathy. The patient was given haloperidol and recovered well. The brain MRI showed the integrity of both corpus Luysii.

CONCLUSION

Hemiballismus has been classically characterized as pathognomonic of a lesion in the contralateral corpus Luysii. However, many cases due to an extraluysian lesion of the striatum, caudate or thalamus have been reported recently. Prognosis is benign in most cases.

Transient hemiballism caused by a small lesion of the subthalamic nucleus

Hemiballism is most commonly caused by ischemic stroke and most cases have a favorable prognosis. Lesions directly involving the subthalamic nucleus (STN) are the cause of a minority of cases but are usually associated with poor prognosis. We report two patients with a small STN lesion who presented with transient hemiballism. A small lesion confined to and only focally affecting the STN may cause hemiballism yet may have excellent outcome. Precise evaluation of the affected region with MRI is useful in predicting the prognosis.

Clinical study of 39 patients with atypical lacunar syndrome

The aim of this study was to describe the clinical characteristics of atypical lacunar syndrome (ALS) based on data collected from a prospective acute stroke registry. In total, 2500 acute stroke patients were included in a hospital based prospective stroke registry over a 12 year period, of whom 39 were identified as having ALS and radiologically proven (by computed tomography or magnetic resonance imaging) lacunes. ALS accounted for 1.8% of all acute stroke patients, 2.1% of acute ischaemic stroke, and 6.8% of lacunar syndromes. ALS included dysarthria facial paresis (n = 12) or isolate dysarthria (n = 9), isolated hemiataxia (n = 4), pure motor hemiparesis with transient internuclear ophthalmoplegia (n = 4), pure motor hemiparesis with transient subcortical aphasia (n = 3), unilateral (n = 2) or bilateral (n = 3) paramedian thalamic infarct syndrome, and hemichorea hemiballismus (n = 2). Atypical lacunar syndromes were due to small vessel disease in 96% of patients. Atherothrombotic infarction occurred in one patient and cardioembolic infarct in another, both presenting pure dysarthria. Outcome was good (in hospital mortality 0%, symptom free at discharge 28.2%). After multivariate analysis, the variables of speech disturbances, nausea/vomiting, ischaemic heart disease, and sensory symptoms were found to be significantly associated with ALS. In conclusion, atypical lacunar syndrome is an infrequent stroke subtype (one of each 14 lacunar strokes). ALS occurred in 6.8% of lacunar strokes. Isolated dysarthria or dysarthria facial paresis were the most frequent presenting forms. The prognosis of this infrequent non-classic lacunar syndrome is good.

Ballism after stroke responds to standard physical therapeutic interventions

OBJECTIVE

To report the effects of noninvasive standard physical therapy (PT) interventions on an involuntary movement disorder after stroke.

DESIGN

Single case with clinical follow-up over 2 years.

SETTING

Inpatient stroke and rehabilitation services and outpatient clinic.

PARTICIPANT

A man with acute bilateral ballism after unilateral subthalamic infarction.

INTERVENTIONS

Rhythmic coordinated bilateral limb movements and firm tactile stimulation to the hand.

MAIN OUTCOME MEASURES

We had not anticipated that dyskinesia itself would specifically improve during treatment. Consequently, we used qualitative clinical observations, including review of videotaped performance, and self-reported limb control. Hypotheses concerning treatment effects were developed after data collection.

RESULTS

Involuntary movements recurrently improved within treatment sessions.

CONCLUSIONS

PT may improve dyskinesia after stroke. The benefit may be adjunctive or alternative to current invasive treatments of movement disorders after brain injury and merits confirmation. The improvements are consistent with current research indicating that (1) intact cortical, subcortical, cerebellar, and spinal areas interact to generate bilateral rhythmic limb movements that can overcome dyskinesia and (2) tactile stimulation can improve motor deficits associated with basal ganglia disorders. Finally, because functional activities assessments improved our evaluation of ballism, these should be routinely used along with conventional neurologic examination to assess involuntary movement disorders.

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.

Somatotopy in the basal ganglia: experimental and clinical evidence for segregated sensorimotor channels

Growing experimental and clinical evidence supports the notion that the cortico-basal ganglia-thalamo-cortical loops proceed along parallel circuits linking cortical and subcortical regions subserving the processing of sensorimotor, associative and affective tasks. In particular, there is evidence that a strict topographic segregation is maintained during the processing of sensorimotor information flowing from cortical motor areas to the sensorimotor areas of the basal ganglia. The output from the basal ganglia to the motor thalamus, which projects back to neocortical motor areas, is also organized into topographically segregated channels. This high degree of topographic segregation is demonstrated by the presence of a well-defined somatotopic organization in the sensorimotor areas of the basal ganglia. The presence of body maps in the basal ganglia has become clinically relevant with the increasing use of surgical procedures, such as lesioning or deep brain stimulation, which are selectively aimed at restricted subcortical targets in the sensorimotor loop such as the subthalamic nucleus (STN) or the globus pallidus pars interna (GPi). The ability to ameliorate the motor control dysfunction without producing side effects related to interference with non-motor circuits subserving associative or affective processing requires the ability to target subcortical areas particularly involved in sensorimotor processing (currently achieved only by careful intraoperative microelectrode mapping). The goal of this article is to review current knowledge about the somatotopic segregation of basal ganglia sensorimotor areas and outline in detail what is known about their body maps.

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 from a parietal stroke in a Parkinson patient

Stroke-induced hemiballismus (HB) has been reported to improve motor function in people with Parkinson's disease (PD). We report on a patient who developed HB from a parietal infarct. The HB was improved by very low-dose clozapine but the HB did not improve the parkinsonism. This suggests that HB itself, whether from a lesion in the subthalamic nucleus or elsewhere, is not what improves motor function in PD; instead, the physiological function of the damaged structure is the determining factor.

Incidence of vascular hemiballism in the population of Belgrade

Hemiballism is a relatively rare hyperkinetic disorder with unknown incidence. Stroke is the most common cause of hemiballism (vascular hemiballism), responsible for the disorder in 50% to 100% of cases. We studied the incidence of vascular hemiballism in the population of Belgrade (Serbia) 40 years of age or older during the period 1 January 1991 to 31 December 2002. During that time period, 37 patients with hemiballism due to stroke were diagnosed. The annual incidence rates varied from 0.14 to 0.87/100,000 (average 0.45/100,000) of general population.

Hemiballism: revisiting a classic disorder

Hemiballism is a rare movement disorder that presents with unilateral flinging movements of the limbs. In traditional teaching, it has been characterised as almost pathognomonic of a lesion in the subthalamic nucleus (STN). The prognosis was described as grave, with severe disability and death in many cases. However, review of more recent reports shows that the STN is directly involved in only a minority of cases. The prognosis is benign in most cases, with almost all patients responding well to treatment and many having spontaneous remission, although long-term prognosis of cerebrovascular disease may not be so good. There have also been recent insights into the pathophysiology of hemiballism, which have emphasised the importance of altered firing patterns in basal-ganglia structures. Recent studies have pointed to previously unrecognised causes, particularly non-ketotic hyperosmolar hyperglycaemia and complications of HIV infection, that may account for a substantial proportion of cases of hemiballism.