Abstract Details

Title A Case of Hemichorea-Hemiballism Following a Cortical Stroke from Occlusion of an Anomalous Accessory Middle Cerebral Artery

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 13-003

Background

PSMDs are rare with an estimated overall prevalence between 1-4%. The pathogenesis of stroke-related chorea is still incompletely understood; however, may involve injury to the cortico-basal ganglia-thalamo-cortical circuit. Furthermore, the presence of coexisting accessory MCA (aMCA) has not been previously described.

Objective To highlight a remarkable example of a post-stroke movement disorder (PSMD) in the setting of an embryologic vascular anomaly.

Design/Methods Not applicable

Results An 84-year-old ambidextrous man presented to the emergency department with right-sided hemiparesis, severe dysarthria, and global aphasia (NIHSS 14). His medical history included atrial fibrillation, hypertension, hyperlipidemia, type 2 diabetes mellitus, and previously treated tuberculosis complicated by pulmonary hemorrhage. He was excluded from acute thrombolysis due to an elevated coagulable panel while on apixaban. Imaging studies included a CT head with early ischemic changes; a CTA head/neck demonstrating an occluded left ICA terminus and proximal ACA with a patent MCA; and a CT perfusion illustrating a left cortical 5ml core with a 207ml penumbra, which was out of proportion to the previous angiography. The patient underwent mechanical thrombectomy with partial recanalization (TICI 2C). Post-reperfusion, an incidental aMCA was revealed, supplying the affected regions seen on the previous CT perfusion scan. Two days after the initial presentation, the patient developed new onset large-amplitude ballistic movements of his right arm and leg consistent with hemichorea-hemiballism. Subsequent MRI brain showed acute infarcts isolated to the left cerebral cortex (i.e. orbitofrontal, prefrontal, and precentral territories). Low-dose risperidone was prescribed. At his 1-month outpatient follow-up appointment, the patient’s involuntary movements had resolved.

Conclusions

Hemichorea-hemiballism can result from isolated cortical insults. Multiple radiographic modalities, both pre- and post-symptom onset, demonstrated no direct basal ganglia or thalamus involvement. Therefore, it is possible that blood supply to these areas originates from an unaffected vessel, such as the native MCA.

Authors/Disclosures
Priyanka Moondra, DO (Northwell Health) PRESENTER	Dr. Moondra has nothing to disclose.
Vishal Gupta, DO (Sentara Healthcare)	Dr. Gupta has nothing to disclose.
Ritesh Ramdhani, MD (Northwell Health)	Dr. Ramdhani has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Accorda. Dr. Ramdhani has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amneal. The institution of Dr. Ramdhani has received research support from NIH. Dr. Ramdhani has received research support from Parkinson Alliance.
Jeffrey M. Katz, MD (North Shore University Hospital)	Dr. Katz has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for Katz Medical Consulting. The institution of Dr. Katz has received research support from Medtronic.
Rohan Arora, MD	The institution of Dr. Arora has received research support from Bayer.
Richard Libman, MD, FAAN (Northwell Health)	Dr. Libman has nothing to disclose.