“I Can't Control My Arm”

8/26/2018

Philippine MinnesotanLIMA with Chief Complaint retrograde flow

Medical AssociationLAD

Case Presentation “I can’t control my arm”

Kristine Domingo, DO August 16, 2018

HPI History

- 68 year old male presented for involuntary • Past Medical History: Hypertension erratic movements of his left arm • Past Surgical History: None - Unable to stop or control the movements despite all efforts • Family History: No significant neurological history - Abrupt in onset • Social History: - Began upon waking up – Tobacco: 20 pack year history, quit 20 years ago - Wife reports that he has been more sleepy – Alcohol: Occasional beer: Max 2 beers, 2-3x per week and more agitated compared to normal – No illicit drug use - At baseline he is easy going with a sense of • Medications: Amlodipine 10 mg humor • Allergies: NKDA

Physical Exam Physical Exam • Mental status: Lethargic & irritable, Oriented x4. • Sensation: Intact to light Reflexes: • Speech: Dysarthric speech with minimal output. touch, pinprick and Comprehension intact. vibration. 2 2 • CN: II-XII intact with no abnormalities 2 2 • Motor: • Coordination: Finger to nose and heel to shin intact 2 2 – Strength: 5/5 strength throughout on the right. Difficulty 3 3 – Tone: Mild rigidity in LUE, inability to relax controlling movements on – Bulk: Normal 1 1 the left FTN. – Non-rhythmic, involuntary, rapid movements of the LUE that persisted into sleep

1 8/26/2018

Vitals and Labs Summary

• Vitals: Acute onset: – BP (141/62) – (170/97) • Non-rhythmic, involuntary, rapid – Pulse: 80’s movements of the LUE that persisted into – RR: 16 sleep – Afebrile • Dysarthria • CBC & CMP: unremarkable • Lethargy • LDL: 99 • A1c: 5.8

Video of movements Localization & Differential

• Where?

• What?

Differential Diagnosis CT Head • Hemiballismus due to: • Stroke – Hemorrhagic – Ischemic • Traumatic brain injury • ALS • Non-ketotic hyperglycemia • Mass lesion/neoplasms • AVM • Demyelination • Infection

2 8/26/2018

CT head CTA Head and Neck

• Unremarkable without evidence of aneurysm, or vascular malformation. Mild plaque at the carotid bifurcation.

MRI MRI Coronal & Sagittal images

Hemiballismus

Hospital Course: Chorea, Athetosis & • Started on benzodiazepines & Haldol with minimal improvement in symptoms Hemiballismus • Started on Lisinopril for better blood pressure management Common Causes & Management • It was later revealed that patient was non- compliant with his home anti-hypertensive medication, Amlodipine • Discharged to rehab facility

3 8/26/2018

Abnormal Movements Video of the Movements

• Chorea • Chorea: – Fluid, unpredictable, non-rhythmic, jerky, non- – https://www.youtube.com/watch?v=xW6LciTL suppressible and involuntary movement oEA • Athetosis • Athetosis: – Slow chorea, can be dystonic, predominantly distal – https://www.youtube.com/watch?v=J_wIDm1_ • Hemiballismus ax4 – Unilateral, rapid, non-rhythmic, non-suppressible, • Hemiballismus: wildly flinging movement – https://www.youtube.com/watch?v=fCL7RWa – Severe form of Chorea C3RA

History - Chorea History – Athetosis

Saint Vitus’s

Dance Thomas William Hammond Sydenham

Dancing Mania Athetosis = Without Position

Causes History – Hemiballismus • Chorea – Huntington’s disease – Hyperthyroidism, hypoparathyroidism, hyperglycemia – Pregnancy, OCP’s, Sydenham – Stroke, SLE, Auto-immune, Paraneoplastic, neoplasm – Drugs, toxic-metabolic • Athetosis – Huntington’s disease – Cerebral Palsy – Asphyxiation – Neonatal Jaundice – Stroke • Hemiballismus – Stroke: Hemorrhagic or Ischemic – Traumatic brain injury – ALS, Non Ketotic hyperglycemia – Mass lesion/neoplasms, AVM, Demyelination, Infection

4 8/26/2018

Causes - Chorea Causes – Athetosis

• Chorea • Athetosis – Huntington’s disease – Huntington’s disease – Hyperthyroidism, hypoparathyroidism, hyperglycemia – Cerebral Palsy – Pregnancy, OCP’s, – Asphyxiation – Sydenham’s – Neonatal Jaundice – Stroke – Fahr’s syndrome – Wilson’s disease – Stroke – SLE, Auto-immune, Paraneoplastic, neoplasm – Drugs, toxic-metabolic causes

Causes - Hemiballismus Anatomy

• Hemiballismus – Stroke: Hemorrhagic or Ischemic – Non Ketotic hyperglycemia – Traumatic brain injury – ALS – Mass lesion/neoplasms – AVM – Demyelination – Infection

MRI Coronal & Sagittal images Mechanism

5 8/26/2018

Treatment of Hemiballismus Hemiballismus - Prognosis

• Antipsychotics and Dopamine Blockade – Tetrabenazine, haloperidol, olanzapine, • Improving prognosis over the pherphenazine, pimozide, chlopromazine years • Anti-convulsants • Self limited if due to – Carbamazepine, valporic acid and topiramate stroke/hemorrhage • Benzodiazepines • Lasting 6-8 weeks on average • Botox • DBS

References

• Gale J. T., Amirnovin R., Wiliams Z., Flaherty A. W. & Eskandar, E. N. (2008). "Symphony to cacophony: Pathophysiology of the human Basal Ganglia in Parkinson disease". Neuroscience and Biobehavioral Reviews. 32: 378–387. doi:10.1016/j.neubiorev.2006.11.005. • Das RR, Romero JR, Mandel A (2005). "Hemiballismus in a patient with Contralateral Carotid Artery Occlusion". Journal of the Neurological Sciences. 238: S392–S392. doi:10.1016/S0022-510X(05)81507-2. • Wild, EJ; Tabrizi, SJ (November 2007). "The differential diagnosis of chorea". Practical Neurology. 7(6): 360– 73. doi:10.1136/pn.2007.134585. PMID 18024776. • Lopez JV, Sibenaller S, Ding D, Riviere CN (2007). "Toward filtering of athetoid movement with neural networks". Engineering in Medicine and Biology Society. 29th Annual International Conference of the IEEE. doi:10.1109/iembs.2007.4352569. Thank you • Vidailhet M, Yelnik J, Lagrange C, et al. (August 2009). "Bilateral pallidal deep brain stimulation for the treatment of patients with dystonia-choreoathetosis cerebral palsy: a prospective pilot study". Lancet Neurol. 8(8): 709–17 • Francisco GE (2006). "Successful treatment of posttraumatic hemiballismus with intrathecal baclofen therapy". American Journal of Physical Medicine & Rehabilitation. 85 (9): 779– 782. doi:10.1097/01.phm.0000233173.32432.6f. PMID 16924190. • Sitburana O, Ondo W (2006). "Tetrabenazine in hyperglycemic-induced hemichorea-hemiballismus". Movement Disorders. 21 (11): S353–S354. doi:10.1002/mds.21100. PMID 16986158. • Gimenez-Munoz A, Alarcia R, Ledesma L, Ara JR (2008). "Pseudoballism secondary to spinal trauma". Neurologia. 23 (5): 315–318. PMID 18247185. • Postuma RB, Lang AE (2003). "Hemiballism: revisiting a classic disorder". Lancet Neurology. 2 (11): 661– 668. doi:10.1016/S1474-4422(03)00554-4. PMID 14572734. • Mukand JA, Fitzsimmons C, Wennemer HK, Carrillo A, Cai CB, Bailey KM (2005). "Olanzapine for the treatment of hemiballismus: A case report". Archives of Physical Medicine and Rehabilitation. 86 (3): 587– 590. doi:10.1016/j.apmr.2004.05.012. PMID 15759249. • Gamez J, Corbera-Bellalta M, Mila M, Lopez-Lisbona R, Boluda S, Ferrer I (2008). "Chorea-ballism associated with familial amyotrophic lateral sclerosis. A clinical, genetic, and neuropathological study". Movement Disorders. 23 (3): 434–438. doi:Kim HJ, Moon WJ, Oh J, Lee IK, Kim HY, Han SH (2008). "Subthalamic lesion on MR imaging in a patient with nonketotic hyperglycemia-induced hemiballism". American Journal of Neuroradiology. 29 (3): 526– 527. doi:10.3174/ajnr.A0927. PMID 18184834. • Temel Y, Blokland A, Steinbusch HW, Visser-Vandewalle V (2005). "The functional role of the subthalamic nucleus in cognitive and limbic circuits". Progress in Neurobiology. 76 (6): 393– 413. doi:10.1016/j.pneurobio.2005.09.005. PMID 16249050. • Driver-Dunckley E, Evidente VG (2005). "Hemichorea-hemiballismus may respond to topiramate". Clinical Neuropharmacology. 28 (3): 142–144. doi:10.1097/01.wnf.0000164160.71206.a3. PMID 15965315.