Harinoor Mann1, Kevin Kelly2, Timothy Leichliter2
1Summa Health System Akron Campus Building 3, East Pavilion, 2Allegheny Health Network
Objective:
Mania and hemiballismus are rare presenting features of acute ischemic stroke. We present a unique case of acute subthalamic stroke presenting with mania preceding hyperkinetic movements by several days making the diagnosis challenging and precluding the patient from acute stroke care.
Background:
66 year old patient presented with abnormal movements. The patient’s symptoms began with sudden onset of increased activity levels, pressured speech, and insomnia. Four days later he presented to the hospital with acute onset of uncontrolled flailing and pain in the left arm and leg. MRI brain revealed an acute right subthalamic infarct. He was diagnosed with post stroke mania and hemiballismus.
Conclusions:
Hemiballismus is a rare presenting symptom of acute stroke. Widely accepted pathophysiology behind hemiballismus is a structural lesion in the subthalamic nucleus. The subthalamic nucleus contains glutaminergic neurons with projections to the globus pallidus interna. The glutaminergic neurons increase the activity of the globus pallidus interna, which contains GABAergic neurons that, in turn, decrease the activity of the thalamus and inhibit movement. Lesions of the subthalamic nucleus can disrupt the inhibition of movement by the globus pallidus interna and results in hyperkinetic movements like hemiballismus. The subthalamic nucleus has a role is mood, memory and behavior. Studies have shown to have variable effects of subthalamic deep brain stimulation on working memory and response inhibition performance and some reported cases with aggressive impulsive episodes, suicide and suicidal attempts, apathy, severe depression, psychosis, and hypomania following bilateral sub thalamic nucleus DBS. Our patient presented with acute onset of mania preceding development of hemiballismus by several days making the case diagnostically challenging. On literature review, we could not find a case with this presentation. With this case, we add to the multitude of presentation of acute stroke since acute stroke is a medical emergency and requires prompt management.