Hemichorea in a patient with ipsilateral cortical infarction: a case report

A 78-Year-Old Woman with Sudden Onset of Left-Sided Hemiballismus

BACKGROUND Hemiballismus is the most severe form of chorea and is a hyperkinetic disorder characterized by involuntary, high-amplitude movements of the ipsilateral arm and leg, due to lesions of the contralateral side of the central nervous system. Ischemic or hemorrhagic strokes and nonketotic hyperglycemia are predominant etiologies of hemiballismus. Case reports highlighting hemiballismus associated with temporal and parietal lobe infarcts have been published, although research of frontal lobe involvement is limited. CASE REPORT A 78-year-old woman presented to the Emergency Department with sudden-onset left-sided hemiballismus. On examination, she was alert, oriented to self and time, and able to follow commands. Her neurologic examination was notable for left-sided hemiballismus, described by the provider as periodic, uncontrolled, and involving a "flinging" motion of the left upper and lower extremities, sparing the face. She was treated with benzodiazepines in the Emergency Department and administered intravenous levetiracetam. Computed tomography of the head without contrast revealed an old left basal ganglia lacunar infarct. The patient was then admitted to the inpatient service, where magnetic resonance imaging of the brain revealed an acute punctate left superior frontal gyrus cortical infarct. Outpatient electroencephalogram revealed right anterior hemisphere dysfunction. CONCLUSIONS We describe a patient with left-sided sudden onset hemiballismus with an acute infarct of the ipsilateral superior frontal gyrus. This case highlights that brain lesions separate from the basal ganglia can induce hemiballismus, particularly within the frontal lobe, which warrants further research into precentral sulcus functioning and its role in modulating motor activity.

Recurrent hemichorea in an adolescent with systemic lupus erythematosus and previous ipsilateral cerebral infarction

Systemic lupus erythematosus (SLE) can present with movement disorders, among which chorea is closely associated with antiphospholipid (aPL) antibodies. Brain imaging results obtained in patients with chorea are generally inconsistent with the clinical manifestation of chorea; moreover, medical tests for hemichorea, which are expected to reveal distinct localization, may show negative findings. Herein, we present a case of a 15-year-old girl with SLE who had a history of left cerebral infarction; tests revealed elevated aPL levels, and she developed recurrent left hemichorea 2 years later. Brain magnetic resonance imaging (MRI) results revealed no acute lesions during each episode of involuntary movements, and an MRI perfusion scan failed to provide an explanation for the asymmetric presentation. Although various hypotheses have been proposed regarding the mechanism underlying the occurrence of chorea, some scenarios still remain unexplained. Further investigation on the pathophysiology of chorea in SLE may be warranted to clarify its prognosis.

Motor Phenomena Associated With Leucine-Rich Glioma-Inactivated (LGI1) Emi-Encephalitis

LGI1 encephalitis is a rare immune-mediated brain disorder. Its typical features include faciobrachial dystonic seizures (FBDS), startle reactions, chorea, myoclonus, atypical parkinsonism, cogni-tive impairment, and personality changes. We report the case of a 57-year-old woman presenting with distinct patterns of involuntary movements, including faciobrachial dystonic spasms, dyskinetic movements, and chorea. Magnetic resonance imaging (MRI) and tests on blood and cerebrospinal fluid (CSF) demonstrated encephalitis involving the right temporal lobe and caudate nucleus and associated with LGI1-antibody. LGI1 encephalitis may present with simultaneous distinct patterns of movement disorders depending on the cortical and subcortical structures involved in the disease.

Post-stroke Chorea in the Neurology Department of Ignace Deen Hospital of Conakry, Guinea

INTRODUCTION

Chorea is an uncommon complication of stroke. The pathophysiology, the exact location of the lesions, and the evolution of this type of chorea are still poorly understood. The objective was to describe the epidemiological, clinical, and imaging profile of post-stroke chorea in a tropical environment in the context of a stroke epidemic.

MATERIAL AND METHODS

We conducted a five-year retrospective observational study from 2015 to 2020 on stroke patients who presented with chorea in our department. Epidemiological, clinical, and imaging data were registered.

RESULTS

Fourteen patients presented with chorea after their stroke, a frequency of 0.6%. The average age was 57.1 years with a male predominance. Hypertension was the cardiovascular risk factor in half of the patients; three patients (21.4) were diabetic. Chorea was the initial manifestation of the stroke in eight patients (57.1%). Thirteen patients (92.9%) had an ischaemic stroke and one had a cerebral haemorrhage. The middle cerebral artery (MCA) was involved in nine patients (64.3%), the anterior cerebral artery (ACA) in three patients (21.4%), and two patients (14.3%) had posterior cerebral artery (PCA) involvement. The lesions were cortical in five patients (35.7%), five other patients (35.7%) had a deep location, and four patients (28.6%) had both deep and cortical locations of their lesions. The structures affected were the lentiform nucleus (50%), the insula (35.7%), the caudate nucleus (14.3%), and the thalamus (14.3%).

CONCLUSION

Post-stroke chorea is poorly studied in the tropics. In the presence of any acute abnormal movement associated with cardiovascular risk factors, post-stroke chorea should be considered. Recovery is rapid when treated early.