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Etiology, Treatment Options and Prognosis of Post- Lesions: Etiology, Stroke Movement Disorders

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Etiology, Treatment Options and Prognosis of Post- Lesions: Etiology, Stroke Movement Disorders REVIEW ARTICLE http://dx.doi.org/10.14802/jmd.16008 / J Mov Disord 2016;9(2):63-70 pISSN 2005-940X / eISSN 2093-4939 Movement Disorders ABSTRACT Post-stroke movement disorders are uncommon, but comprise an important part of secondary move- Following ment disorders. These exert variable and hetero- geneous clinical courses according to the stroke le- sion and its temporal relationships. Moreover, the Cerebrovascular predominant stroke symptoms hinder a proper di- agnosis in clinical practice. This article describes the etiology, treatment options and prognosis of post- Lesions: Etiology, stroke movement disorders. Key Words Treatment Options Stroke; Movement disorders; Etiology; Treatment; and Prognosis Prognosis. Do-Young Kwon Department of Neurology, Korea University College of Medicine, Ansan Hospital, Ansan, Korea Received: February 4, 2016 Revised: February 23, 2016 Accepted: March 7, 2016 Corresponding author: Do-Young Kwon, MD, PhD, Department of Neurology, Korea Univer- sity College of Medicine, Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea Tel: +82-31-412-5150 Fax: +82-31-412-5154 E-mail: [email protected] cc This is an Open Access article distributed under the terms of the Creative Commons Attri- bution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which per- mits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2016 The Korean Movement Disorder Society 63 JMD J Mov Disord 2016;9(2):63-70 INTRODUCTION feature significantly greater involvement of deep br- ain lesions affecting the basal ganglia, thalamus, in- Movement disorders are rare, but may present as ternal capsule, diencephalon, and mesencephalon than a consequence of stroke.1,2 Involuntary movements stroke patients without movement disorders. Strokes related to any type of stroke comprise one important in deep brain lesions are also associated with a high- part of secondary movement disorders. Post-stroke er probability of AIM (odds ratio 3.38, 95% confid- movement disorders are defined as paroxysmal, re- ence interval 1.64 to 6.99).1 For cortical lesions, the current, transient, permanent and delayed move- areas most commonly associated with post-stroke ments in the acute phase or as a delayed syndrome movement disorders include those involved in the occurring months or years after vascular events.1,3 cortical motor system, including the primary motor, Thus, movement disorder after stroke is a heteroge- supplementary motor and premotor cortical areas. neous condition. Abnormal involuntary movements The parietal cortex is also involved in processing so- (AIM) following stroke can be classified as hyper- matosensory information related to movement. How- kinetic or hypokinetic.4 Various presentations in- ever, “pure” or “isolated” stroke-related cortical move- cluding tremor, chorea-ballism, dystonia, athetosis, ment disorders are rare, as most “cortical” strokes myoclonus, ataxia, and parkinsonism have been as- also affect subcortical structures. Therefore, consid- sociated with vascular brain lesions.1,2,5,6 The time eration is needed for the possibility that many “st- course for the development of AIM attributed to ructural” cortical strokes actually have functional stroke is not easily predicted, as the course differs defects arising from lesions affecting subcortical according to the type of AIM; they can manifest with structures. Several case reports have described cor- a variety of presentations or even in the same move- tical stroke-related movement disorders, including ments.4 Similar to the typical stroke symptoms, the parietal lobe stroke with choreo-ballism,8 focal dys- duration of AIM also varies from paroxysmal and/ tonia,9,10 arm levitation due to distortion of the body or transient to persistent and progressive.1 The mani- schema and athetosis.11 Frontal lobe stroke is asso- festation of stroke varies even in the same vascular ciated with asterixis (negative myoclonus),7 second- territory.7 Accordingly, mixed movements are one of ary painless leg moving toe syndrome,12 and resting the characteristics of secondary AIM associated with and action tremor (with strokes affecting the ante- a stroke lesion with an extensive involvement. Al- rior cerebral artery territory).7,13 Structural cystic le- though the frequency of AIM following stroke is low, sions with mass effects of the middle fossa involving it is important to know the possible clinical condi- the fronto-temporo-parietal area can mimic Holme’s tions, its course and symptoms and the proper man- tremor.14 Alleviation of a previous tremor is also pos- agement strategies, as these aspects could consider- sible after frontal cortical stroke.15 Some cortical ably affect a stroke patient’s quality of life as much as stroke-related movement disorders feature a laterali- the paretic stroke symptoms. This article describes ty component: bilateral cortical ptosis can occur with the etiology, treatment options and prognosis of post- a large right-side, hemispheric lesion.16,17 Secondary stroke movement disorders. restless legs syndrome (RLS) after stroke has been reported with temporo-occipital cortical lesions, as ETIOLOGY OF POST-STROKE well as with stroke affecting the basal ganglia, thala- MOVEMENT DISORDERS mus, internal capsule and pons.18 Stroke lesion location Stroke subtypes Post-stroke movement disorders can develop in A large epidemiologic study previously examined any stroke subtype and at any brain level of the mo- post-stroke movement disorders but was limited by tor circuit. In the extrapyramidal system, however, a small number of patients. However, in that study, the basal ganglia and thalamus are the primary le- basal ganglia and thalamus involvement in stroke sion sites associated with post-stroke movement was frequent.2 Overwhelmingly, the typical stroke disorders.1,4 A comparison between stroke patients symptoms that occur in the acute phase play a role and case-controls (without movement disorders) re- in overlooking combined movement disorders. In vealed that stroke patients with movement disorders one registry study that enrolled 1,500 consecutive st- 64 Management of Post-Stroke Movement Disorders Kwon DY roke patients, 59 (3.9%) developed post-stroke mo- MELAS vement disorders, with chorea as the most common Mitochondrial encephalomyopathy, lactic acido- movement disorder subtype.1 Ischemic stroke can be sis, and stroke-like episodes (MELAS) syndrome is etiologically classified as a small vessel disease, large a distinct clinical syndrome involving skeletal mus- vessel disease or cardioembolic stroke.19 Among the cles and the brain.29 As the name suggests, the most ischemic stroke subtypes, multifocal small vessel st- common movement disorder in MELAS is myoclo- roke is the most commonly associated with move- nus. Parkinsonism and gait freezing are other symp- ment disorders following stroke, and it is the leading toms associated with MELAS.30-32 Nakagaki et al.33 cause of post-stroke AIM. However, cardioembolic reported a case of chorea-ballism in MELAS that stroke and large- and medium-sized atherosclerotic might accelerate hyperglycemic movement disor- stroke are also included in the etiology of movement ders. Although brain lesions in MELAS are not con- disorders.2,20 Hemorrhagic stroke has a high proba- fined to a specific vascular territory,34 the brain pa- bility of developing post-stroke movement disor- thology might contribute to most of the related se- ders when compared to ischemic stroke. Generally condary movements. speaking, there is no specific preference to the vas- cular region or subtype in post-stroke movement Moyamoya disease disorders, with only a trend for some of the clinical Moyamoya disease is defined by progressive oc- factors described.21 Chronic small vessel disease or clusion of the internal carotid artery and arteries in Binswanger’s disease can develop into secondary the circle of Willis.35 Movement disorders in moy- parkinsonism (vascular parkinsonism). Vascular amoya disease are rare and have been reported main- parkinsonism is phenomenologically characterized ly in pediatric patients.36-38 Regardless of age, the most by bilateral slowness and rigidity, which is predom- common AIM in moyamoya disease is chorea.39 The inant in the lower extremities, causing gait problems reported occurrence in one study was 31 of 42 (67.4%) and lower-body parkinsonism.22 Subcortical small patients, which was followed by dystonia in 8 of 42 vessel pathology, rather than the typical Lewy body (17.4%) patients, with a mean age of onset of 21.4 pathology, was reported in the pathologic study of years.40 In another study, 5 of 513 pediatric patients vascular parkinsonism.23 with moyamoya disease had AIM, 4 had chorea, and one had dystonia. The symptoms improved in all MOVEMENT DISORDERS IN cases after bypass surgery, suggesting that cerebral SPECIFIC STROKE SYNDROMES ischemia even in the absence of stroke lesions might be a pathogenic mechanism in moyamoya disease.37 CADASIL Another retrospective review study of 316 surgical- Cerebral autosomal dominant arteriopathy with ly treated children with moyamoya disease report- subcortical infarcts and leukoencephalopathy (CA- ed that 10 (3.2%) children had chorea that resolved DASIL) is a progressive vascular disease character- following the revascularization surgery. The same ized by migraine headache, stroke syndromes, and authors postulated that dysfunction of the basal gan- dementia.24
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