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Hemiballismus: /Etiology and Surgical Treatment by Russell Meyers, Donald B J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.2.115 on 1 May 1950. Downloaded from J. Neurol. Neurosurg. Psychiat., 1950, 13, 115. HEMIBALLISMUS: /ETIOLOGY AND SURGICAL TREATMENT BY RUSSELL MEYERS, DONALD B. SWEENEY, and JESS T. SCHWIDDE From the Division of Neurosurgery, State University of Iowa, College ofMedicine, Iowa City, Iowa Hemiballismus is a relatively uncommon hyper- 1949; Whittier). A few instances are on record in kinesia characterized by vigorous, extensive, and which the disorder has run an extended chronic rapidly executed, non-patterned, seemingly pur- course (Touche, 1901 ; Marcus and Sjogren, 1938), poseless movements involving one side of the body. while in one case reported by Lea-Plaza and Uiberall The movements are almost unceasing during the (1945) the abnormal movements are said to have waking state and, as with other hyperkinesias con- ceased spontaneously after seven weeks. Hemi- sidered to be of extrapyramidal origin, they cease ballismus has also been known to cease following during sleep. the supervention of a haemorrhagic ictus. Clinical Aspects Terminology.-There appears to be among writers on this subject no agreement regarding the precise Cases are on record (Whittier, 1947) in which the Protected by copyright. abnormal movements have been confined to a single features of the clinical phenomena to which the limb (" monoballismus ") or to both limbs of both term hemiballismus may properly be applied. sides (" biballismus ") (Martin and Alcock, 1934; Various authors have credited Kussmaul and Fischer von Santha, 1932). In a majority of recorded (1911) with introducing the term hemiballismus to instances, however, the face, neck, and trunk as well signify the flinging or flipping character of the limb as the limbs appear to have been involved. movements, but in general each observer's concept The patient usually retains a measure of voluntary of the features of hemiballismus represents but an control over the affected member so that acts such abstraction of his own limited experiences. The as walking, putting on slippers, and touching the consequence is that at most clinical demonstrations hand to the face can be performed even if with of a case alleged to be one of hemiballismus one or more members of the audience are moved to assert difficulty. The ballistic movements cannot however " be voluntarily checked for more than a few moments that the case in question is not " really an example at a time. The muscle tonus of the involved limb(s) of hemiballismus, but one of hemichorea, athetosis, may be normal but in many instances is slightly dystonia, or perhaps hysteria. If, on the other diminished (Martin and Alcock), and in consequence hand, the case is presented initially as an instance of the reduced initial tension of the muscles the deep of hemiathetosis or chorea, similar protests may be http://jnnp.bmj.com/ reflexes of the affected limbs are often moderately raised. diminished. The terms athetosis, chorea, and ballismus refer The vast majority of patients are at or beyond to involuntary, non-patterned movements of bodily middle life at the time of onset of hemiballismus. members, which are unpredictable in respect of time as and form. They may be distinguished from the However, reports of patients young as seven myorhythmias, myoclonus, the coarse, alternating (Bonhoeffer, 1930) and eighteen (Bianchi, 1909) and the years have been recorded. There appears to be no tremors of Parkinsonism, fine tremors of significant difference in sex incidence. thyrotoxicosis. They are present in the waking state on September 30, 2021 by guest. Spontaneous recovery is not to be expected and and absent during sleep. They appear both " at rest'" by far the majority of patients succumb within a and during the execution and maintenance of few days to several months ofprogressive exhaustion, "voluntary" movements. In our view, the three cardiac or and varieties may be distinguished from one another on failure, pneumonia (Grinker Bucy, the following grounds. In athetosis the movements *Case I of this communication was reported with motion picture are relatively slow, vermiform and writhing, and in illustrations at the Sixteenth Annual Meeting of the Harvey Cushing Society on August 19, 1948, at San Francisco, Cal. The paper in the limbs are chiefly due to the action of distal its present form was given with motion picture illustrations at the Seventy-fourth Annual Meeting of the American Neurological muscles. The proximal limb muscles may also Association on June 13, 1949, at Atlantic City, N.J. participate. Athetotic movements are character- 115 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.2.115 on 1 May 1950. Downloaded from 116 RUSSELL MEYERS, DONALD B. SWEENEY, AND JESS T. SCHWIDDE istically intermittent so that periods of several quent post-mortem studies have provided over minutes may elapse without the exhibition of fifty instances in which the corpus Luysi has been involuntary activity. In chorea the movements are damaged, though often along with other neural much more sudden and, insofar as the limbs are structures. Indeed, the number of studies in which, concerned, are subtended chiefly by action of the like those of Matzdorff (1927) and Thurel and more distal rather than the proximal muscles. As Grenier (1947), the only demonstrable brain lesion in athetosis, choreic movements are frequently is limited strictly to the corpus subthalamicum is intermittent. Ballistic movements resemble choreic very small. movements in that they also are rapidly executed. In a review of the literature up to 1934, Martin The muscles of the face, neck and/or trunk may or and Alcock (1934) asserted that no case of hemi- may not be involved. The proximal muscles of the ballismus had been fully described in which the limbs are regularly involved, with the consequence corpus subthalamicum was not found damaged. that the limbs exhibit large excursions. Close This extreme position no longer appears tenable, inspection however usually reveals involvement but Whittier's (1947) observation that hemi- also of the more distal limb muscles. In contrast ballism is the " apparently inevitable symptom in to the intermittent activity characteristic of chorea man of destruction of the subthalamic nucleus" is and athetosis, that of hemiballismus is almost probably quite correct. at the wakeful state. ceaselessly play during Lesions Involving Other Structures.-Several cases Additional Clinical Manifestations.-The intellec- of hemiballismus have been reported in which the tual, emotional, and sensory functions are seldom corpus subthalamicum is asserted to have been found deranged in hemiballismus. However, the coexis- intact at necropsy. In these the lesion considered tence of psychological aberrations, vegetative dis- responsible for the hyperkinesia was disclosed in turbances, hemiparesis, dysphasia and/or oculo- other parts of the brain. Protected by copyright. motor disorders with hemiballismus has not in- Lesions of the Afferent or Efferent Fibres of the frequently been reported. In most such instances Corpus Subthalamicum.-In two of the earliest cases necropsy has demonstrated multiple or extended on record, those of Bianchi (1909) and Bonhoeffer lesions involving neural structures other than those (1897), the abnormal movements were imputed considered responsible for the ballistic movements. (Martin, 1928) to lesions at a level ")lower than" Aetiology and Pathology the corpus Luysi, presumably situated so as to destroy its efferent connexions to the midbrain. The pathological process most frequently en- That damage to either the afferent or efferent fibres countered in hemiballismus is a circumscribed of the nucleus might produce hemiballismus was encephalomalacia which is usually the result of postulated in 1939 by Moersch and Kernohan. cerebral thrombosis. Diabetes mellitus not infre- Subsequently, Papez, Bennett, and Cash (1942) quently underlies the thrombotic process. Somewhat described a case which they considered illustrative less frequently small circumscribed hemorrhages of the point. The presence of multiple lesions in and emboli appear to be the responsible agents their case unfortunately equivocates their interpre- (Martin and Alcock, 1934). Other lesions, in- Kelman however, recorded the tation. (1945), http://jnnp.bmj.com/ cluding tuberculoma, gumma, metastatic abscess, necropsy findings of a hemiballistic subject in which metastatic neoplasm, encephalitis and the co-called a small metastatic carcinoma from the lung involved primary degenerative processes of the brain, have the afferent subthalamic tracts. been identified. In two instances trauma has been considered the causative agent (Bucy, 1944; Lesions ofthe Corpus Striatum.-In 1926 Fragnito Schob, 1920). and Scarpini described the necropsy findings in an The anatomical sites at which lesions have been 80-year-old male who had suffered from hemi- encountered may be conveniently described under ballismus for three years before his death. An two main headings. encephalomalacic process had markedly damaged on September 30, 2021 by guest. the medial portion of the putamen and, to a lesser Lesions Involving the Corpus Subthalamicum.- degree, the head of the caudate nucleus. The The structure most frequently involved in hemi- corpus Luysi, medial lemniscus, and fields of Forel ballismus is the corpus subthalamicum contralateral were reported to be undamaged.* Several other to that side of the body exhibiting abnormal move- investigators
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