J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.10.963 on 1 October 1983. Downloaded from

Journal of Neurology, Neurosurgery, and Psychiatry 1983;46:963-965 Letters Table Sodium valproate Number ofmovements (in 30 Treatment of post-traumatic choreo- minutes) athetosis with sodium valproate Serum level Oral dose Major Moderate Minor (pgms/ml) (mgm) Sir: We report a study which establishes 57-0 500 four times daily 0 2 12 the efficacy of sodium valproate in the 46-0 500 thrice daily 0 5 7 treatment of post-traumatic choreo- 20-0 250 thrice daily 2 7 6 athetosis. Below detectable Placebo 13 2 1 A 28-year-old male was admitted to the hospital. At the age of nine years, he fell from a three storey building sustaining that the involuntary movements were not mechanism of action of sodium valproate is severe left sided cerebral damage. He was part of a focal seizure. The muscle activity determined. in coma for about one month, making a was recorded from surface electrodes gradual recovery over the next four placed on the deltoid, biceps and VIJAY CHAND)RA months. During recovery he developed brachioradialis, the three muscles most Department ofNeuroloiogy right sided focal seizures, a right spastic involved in this patient's movement disor- AVERY L SPU:JNT hemiparesis and choreo-athetoid der. The frequency, duration and amp- Departments of Pharmacy Practiice movements of the right arm. On examina- litude of the deflections from the resting and Neuroloi state were WgY tion, the abnormal findings were all on the used to classify the movements MARTIN S RUSINOWrgyjlTZ right side and included a homonymous into major, moderate and minor. Sodium Department ofNeurolog hemianopia, a spastic hemiparesis, mild valproate levels were checked two hours University ofIllinoisaat limb atrophy, a cortical type of sensory after administering the oral medication. Chicago, USSA deficit and a Babinski sign. Choreo- Muscle activity was recorded continuously athetoid movements of the right arm were for 30 minutes each time. present, consisting of flexion-extension of The frequency of major, moderate and the and wrist minor involuntary movements and the cor- Address for reprint requests: Vijay Ira, Protected by copyright. fingers supination, pronation MD, PhD, National Institutes of Health,Chandi and flexion of the and abduction of responding sodium valproate levels are Building, Room 904, 7550 Wisconsin Fedeiral elbow, Avenuue, the shoulder. These movements were shown in the table. As serum sodium val- Bethesda, Maryland 20205, USA absent in sleep and increased by the stress proate levels rose, there was a reduction in induced by rapid questioning. The EEG the frequency of major and moderate showed sharp waves in the left frontal and involuntary movements. The minor References temporal areas and a mild degree of slow involuntary movements observed at higher wave abnormality in the same area. CT of levels of sodium valproate were shorter in 'Chandra V, Wharton S, Spunt AL. Ameliorra- of with sodium le. the head showed a large area of decreased duration and involved fewer muscle groups tion Neurolhemiballismus1982;12:407. valproat density in the left hemisphere with dilata- comparedcompardto moderatemderate and majorma'or 2Ann2 Lenton RJ, Cofti M, Smith RG. Hemiballism tion of the left lateral ventricle. movements, treated with sodium valproate. Br Med us The patient's seizures were well control- The progressive improvement in this 1981;283:17-18. led with phenytoin, phenobarbital and patient's movement disorder as serum 3 McLachlan RS. Valproic acid in Sydenham n's methsuximide. The patient was started on sodium valproate levels increased strongly chorea. Br Med J 1981;283:274-5. sodium valproate at a dose of 250 mg by suggests a cause and effect relationship. 4Sommerville ER, Olanon W. Valproic acii id: mouth three times a day. Within twelve Furthermore, the "blinded" study design treatment of myoclonus in dyssynergia cer re- hours of the first dose, the patient reported used adds strength to the observation. bellaris myoclonica. Arch Neur oll improvement in his involuntary Recently there have been a growing num- Sotan3imi K. Vn 5 Sotaneimi K. Valproic acid in the treatment of movements. After one week, the dose was berberoforeportsreprtsoof theusethe use off sodumsodium vlprvalpro- nonepileptic myoclonus. Arch Neur and oll doubled then increased to 500 mg four ate in diverse movement disorders. Two 1982;39:448-9. http://jnnp.bmj.com/ times a day with a dramatic reduction in groups reported its use for the treatment of 6Suber DA, Riley TL. Valproic acid and normal the frequency of involuntary movements. hemiballism.'2 Other movement disorders computerized tomographic scan iin At this point the patient entered into a con- successfully treated with sodium valproate kinesiogenic familial paroxysmal chore( o-- trolled trial with placebo to establish the include Sydenham's chorea,3 dyssynergia athetosis. Arch Neurol 1980;37:327. of sodium in his cerebellaris efficacy valproate treating myoclonica,' non-epileptic Accepted in revised form 31 May 1983. involuntary movements. A single blind myoclonuse and kinesiogenic familial study design was used. The patient was not paroxysmal choreo-athetosis.' In a previ- aware whether he was on sodium valproate ous report' we emphasised the possible or placebo, as the two looked identical. significance of the rapidity of clinical Recurrent cerebral abscess in hereditary on October 1, 2021 by guest. Since a mechanical recording device was response to sodium valproate. A review of haemorraic telangiectasia used to count the frequency of involuntary other studies25 shows that a similar early movements in a minute time thirty period, response is seen in other movement dis- Sir: Cerebral abscess carries a high mortaLl- observer bias was eliminated, thus avoiding orders. The patient responded within twelve ity, with delay in establishing the diagnosSis the need for a double blind study. Simul- hours of onset of therapy. However, the being an important contributing factorr.I taneous EEG and muscle recordings were biological significance of this observation Recognition of any predisposing causse made. The EEG was recorded to ensure can only be determined once the exact facilitates earlier diagnosis and improv4 'es 963