A case of isolated middle cerebral artery stenosis with hemichorea and moyamoya pattern collateralization

Hemichorea in patients with temporal lobe infarcts: Two case reports

BACKGROUND

Hemichorea and other hyperkinetic movement disorders are uncommon presentations of stroke and are usually secondary to deep infarctions affecting the basal ganglia and thalamus. Therefore, temporal ischemic lesions causing hemichorea are rare. We report the cases of two patients with acute ischemic temporal lobe infarct strokes that presented as hemichorea.

CASE SUMMARY

Patient 1: An 82-year-old woman presented with a 1-mo history of involuntary movement of the left extremity, which was consistent with hemichorea. Her diffusion-weighted imaging (DWI) revealed an acute ischemic stroke that predominantly affected the right temporal cortex, and magnetic resonance angiography of the head showed significant stenosis of the right middle cerebral artery (MCA). Treatment with 2.5 mg of olanzapine per day was initiated. When she was discharged from the hospital, her symptoms appeared to have improved compared with those previously observed. Twenty-seven days after the first admission, she was readmitted due to acute ischemic stroke. Computed tomography perfusion showed marked hypoperfusion in the right MCA territory. An emergency transfemoral cerebral angiogram was performed and showed severe stenosis in the M1 segment of the right MCA. After percutaneous transluminal angioplasty was successfully performed, abnormal movements or other neurologic problems did not occur. Patient 2: A 76-year-old man was admitted to our hospital for a 7-d history of right-upper-sided involuntary movements. DWI showed an acute patchy ischemic stroke in the left temporal lobe without basal ganglia involvement. Subsequent diffusion tensor imaging confirmed fewer white matter fiber tracts on the left side than on the opposite side. Treatment with 2.5 mg of olanzapine per day improved his condition, and he was discharged.

CONCLUSION

When acute hemichorea suddenly appears, temporal cortical ischemic stroke should be considered a possible diagnosis. In addition, hemichorea may be a sign of impending cerebral infarction with MCA stenosis.

Truncal dystonia with isolated middle cerebral artery ischemia: A case report of revascularization therapy for dystonia

Background:

Dystonia is a rare movement disorder with some cases being difficult to treat. Although dystonia can occur as a symptom of moyamoya disease, few studies have reported truncal dystonia occurring with middle cerebral artery (MCA) stenosis. Here, we report a case of truncal dystonia with MCA occlusion.

Case Description:

The patient was a 48-year-old female clerical worker who lived alone. An abnormal cervical posture initially appeared 7 years before (right flexion). Symptoms improved with medication and botulinum toxin injection. Five years before this report, her symptoms worsened, so the dose of oral medication was increased and botulinum treatment was performed, but the symptoms did not improve. The patient showed decreased cerebral blood flow (CBF) in the cortical areas but not in the basal ganglia. We performed superficial temporal artery-MCA bypass surgery because we believed that the dystonia was due to right MCA stenosis. The patient’s symptoms improved immediately after surgery, except for her mild cervical backbend. Seven months after the surgery, the patient’s involuntary movements showed further improvement, and symptoms have not worsened even after 2 years.

Conclusion:

Revascularization therapy improved CBF and truncal dystonia and could be a viable treatment option for dystonia with ischemia in the MCA region. Extensive cerebral ischemia can result in cortical inhibition loss or over-adapted cerebral plasticity and cause dystonia. Revascularization therapy may be useful for patients with dystonia and decreased CBF in the MCA region.

Persistent Hemichorea as a Preceding Symptom of Cerebral Infarction Due to Middle Cerebral Artery Stenosis

We herein report an 84-year-old woman with right middle cerebral artery (MCA) stenosis who presented with persistent left hemichorea preceding cerebral infarction. She visited our hospital on day 9 after the hemichorea onset. Magnetic resonance imaging (MRI) showed no acute cerebral infarction. Magnetic resonance angiography revealed right MCA stenosis. Her hemichorea persisted for 19 days and subsequently disappeared. On day 21, she developed left hemiplegia. Repeat MRI revealed a cerebral infarction in the right putamen. MCA stenosis can present with persistent hemichorea, even in the absence of cerebral infarction. Persistent hemichorea with MCA stenosis may presage cerebral infarction.

[Clinical findings of a patient with hemiballism after superficial temporal artery-middle cerebral artery anastomosis for idiopathic middle cerebral artery stenosis]

A 32-year-old woman experienced several episodes of transient numbness on the left side of her face and body. MR angiography revealed severe stenosis in the right middle cerebral artery (MCA). Abnormal collateral vessel networks were not observed, and idiopathic MCA stenosis was diagnosed. She underwent superficial temporal artery (STA)-MCA anastomosis of the right hemisphere. The surgery eliminated the transient ischemic attacks; however, she developed hemiballism in the left side of her face and left upper limb 2 weeks after the surgery. The ballism disappeared 1.5 years after onset without any treatments. A few patients with development of chorea after STA-MCA anastomosis has been reported in moyamoya disease, but not in those with MCA stenoses. It has been previsouly reported that the development of an involuntary movement might be associated with hypermetabolism in the contra lateral striatum after STA-MCA anastomosis. We considered that a similar mechanism may have caused hemiallism in our patient. We need to recognize that STA-MCA anastomosis could cause hemichorea or hemiballism.