Abstract Details

Title Reversible Ischaemia Without Infarction Presenting as Progressive Hemichorea

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P10 - Poster Session 10 (8:00 AM-9:00 AM)

Poster/Presentation
Number 13-010

Background

Movement disorders, most commonly hemichorea, complicate 1-4% of strokes. Typically, hemichorea begins within days of a stroke affecting the basal ganglia, and gradually resolves over 6 months. However, less well-recognised is the phenomenon whereby progressive hemichorea-hemiballismus may be a symptom of reversible ischaemia without infarction due to critical carotid occlusive disease.

Objective N/A

Design/Methods N/A

Results

A 69 year old smoker presented with a 3 week history of irregular involuntary movements that began in the fingers of her right hand, and spread to involve the whole right arm and then the right foot. She then had a 3 minute episode of dysarthria that prompted presentation to hospital. On admission, she was hypertensive (200/105mmHg), and had marked right hemiballismus-hemichorea with subtle orolingual chorea, which worsened with commencement of antihypertensive therapy. Neurological exam was otherwise normal.

Given the subacute presentation of hemiballismus-hemichorea followed by a TIA, the clinical impression was of a stroke affecting the left basal ganglia. However, MRI head did not reveal acute ischaemia or a prior/recent stroke affecting the left basal ganglia. However, CT angiogram revealed critical 95% stenosis of the left internal carotid artery. All other investigations were normal. The patient underwent a carotid endarterectomy. The hemichorea had resolved 6 weeks later.

Conclusions This case adds to the small but growing body of evidence that hemichorea-hemiballismus may be the presenting symptom of reversible cerebral ischaemia due to ICA stenosis, and can resolve following surgical revascularisation. It should therefore prompt vascular imaging even where there is no evidence of acute infarction on MRI brain imaging. SPECT studies in these cases suggest that the reversible ischaemia may not localise to the basal ganglia, but reflects hypoperfusion of wider striato-thalamo-cortical circuits. Therefore, even when perfusion studies do not directly implicate the basal ganglia, high-grade ICA stenosis associated with contralateral hemichorea warrants consideration of surgical revascularisation.

Authors/Disclosures
Sarah Wrigley, MD PRESENTER	Dr. Wrigley has nothing to disclose.
	No disclosure on file
Sean O'Riordan, MD (St. Vincent's University Hosp)	Dr. O'Riordan has nothing to disclose.