Objective:

To describe a video case of a man with hemiballism secondary to intracranial hemorrhage (ICH).  

Background:

Hemiballismus is a hyperkinetic involuntary movement disorder characterized by intermittent, sudden, violent, involuntary, flinging, or ballistic high amplitude movements involving the ipsilateral arm and leg caused by dysfunction in the central nervous system of the contralateral side. In ballism, the movements are almost ceaseless, predominantly affecting the proximal parts of the limbs with excursions of the entire extremities, which are asynergic, complex, and combined. We report a case of Hemiballismus due to an ICH in the thalamic-subthalamic region.  

Design/Methods:

A 62-year-old man with history of uncontrolled hypertension, presented with three days of acute onset abnormal right-sided movements. The involuntary movements resulted in recurrent falls. On admission his NIHSS was reported as 2, blood pressure was 178/116, and the patient had right upper and lower extremities ballistic movements (proximally) and choreiform movements (distally).  

Results:

CT head showed an 11 mm left thalamic-subthalamic ICH with mild surrounding edema. CTA head and neck did not reveal occlusion or arterio-venous malformations. He was started on risperidone 1mg BID and titrated up to 3mg BID, as the movements were bothering him significantly. He had moderate improvement of involuntary movements. The plan is transition to tetrabenazine, if the movements do not resolve within a month.

Conclusions:

Unilateral movement disorders warrant brain imaging to look for contralateral structural lesions. Hemichorea and hemiballism share similar pathophysiology and are treated with the same drugs. The term "choreoballismus" should be used when features are combined. Hemichorea, with or without hemiballism, is the most frequent post-stroke hyperkinetic movement disorder. Despite the traditional belief that the subthalamic nucleus is the typical anatomical correlate for hemiballism, this hyperkinetic movement disorder has been described following lesions in other locations (thalamus or striatum more frequently than subthalamus).