The Journal of the Arkansas Medical Society Med Journal Dec 2019 | Page 14

CASE STUDY
Intracerebral Cavernoma Presenting as Hemiballismus
Rumyar Vojdanian Ardakani 1 ; Rohit Dhall, MD 2 ; Pradeep Kumbham, MD 3 ; Yohei Harada, MD 3
1
Medical student, UAMS
2
Associate Professor of Neurology, UAMS, Director of Neurodegenerative Disorders, UAMS
3
Resident Physician, UAMS
Abstract
W
hile stroke remains the most
common etiology of acute-
onset hemiballismus, vascu-
lar malformations such as cavernous
angiomas are rarely reported in the
literature. We found cavernous angioma to be
the cause of progressive, unilateral hemiballismus
involving the legs, arm, and face in a 36-year-
old woman. In this article, we present the clinical
course of this patient and review the proposed eti-
ology and diagnosis of hemiballismus.
Introduction
Chorea is a type of hyperkinetic movement
disorder characterized by involuntary movements
that are irregular, abrupt, and unpredictable in na-
ture. Chorea most commonly involves the distal ex-
tremities; however, it can occasionally involve the
trunk and face, resulting in impaired speech and
postural instability. The movements are non-pat-
terned and can have variable direction, speed, and
timing. More severe cases of chorea can present as
proximal and high-amplitude movements that have
a flailing or kicking character, labeled ballismus
when bilateral or hemiballismus when unilateral.
Hemiballismus is much more common, with only a
few case reports of bilateral ballismus in the litera-
ture. 1 While ballismus is usually present at rest, it
often becomes more exaggerated with action.
The etiology of hemiballismus is wide-ranging
and can be classified as either primary or second-
ary. Primary hemiballismus is usually neurode-
generative in nature whereas secondary hemi-
ballismus is often caused by vascular, infectious,
autoimmune, neoplastic, and metabolic causes
that ultimately induce damage to the basal ganglia.
Stroke remains the most common cause by far of
hemiballismus. 2 Cavernous malformations, also
known as cavernomas, rarely cause choreiform
movement disorders and there are few cases re-
ported in the literature. Here we report a case of
intracerebral cavernoma presenting as acute-onset
hemiballismus in a 36-year-old woman.
Case
A 36-year-old woman presented to our
hospital from an outside facility complaining of
involuntary, jerking movements of her left arm,
leg, and face. Two weeks prior to her presenta-
tion, she developed paresthesia in her left fingers
and toes. One week later, she started to develop
abnormal, uncontrollable writhing movements of
her left arm. Over the course of the next week,
these movements progressed to involve her left
face and leg and became progressively higher
in amplitude. At the time of presentation to our
facility, the patient’s movements had progressed
to become hemiballistic in nature. She stated that
these movements were momentarily and mildly
suppressible but mostly continued without break.
She was prescribed benzodiazepines and Tiza-
nidine at an outside clinic with no improvement
in her condition. She ultimately presented to an
outside emergency department for evaluation of
her symptoms. At that time, a CT scan of the brain
was concerning for possible hemorrhagic stroke
and patient was transferred to our facility for
evaluation and management.
Patient’s past medical history was significant
for diabetes mellitus type 2, hypertension, and
anxiety. There was no personal or family history of
similar symptoms. There was no drug usage prior
to the start of her symptoms. At presentation, the
patient’s vitals were normal and her general physi-
cal examination findings were normal. On neuro-
logical exam, patient’s orientation and language
were normal. Cranial nerves function was intact
bilaterally. Sensation and cerebellar exam were
normal as well. Deep tendon reflexes (DTR) were
normally active, with no pathological reflexes.
134 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Motor examination revealed normal tone, normal
bulk, and full strength throughout. However, pa-
tient exhibited continuous writhing movements of
left arm and left leg with intermittent hemiballistic
movements. She also exhibited moderate left facial
hemichorea. These movements did not reduce in
quantity or amplitude with distraction. Routine labs
were normal except elevated blood glucose at 205
mg/dL). Similarly, Hemoglobin A1c was severely
elevated at 14.9% (normal 4.0%-6.0%). Urinalysis
revealed moderate glycosuria (500 mg/dL) and el-
evated urine ketones (15 mg/dL).
Non-contrast computed tomography (CT) im-
aging revealed a hyperdensity within the right in-
sula and sub-insular white matter consistent with
parenchymal hemorrhage of unknown etiology.
Follow-up computed tomography angiogram (CTA)
revealed an irregular and rounded area of low at-
tenuation within the hyperdense insula measuring
approximately 1.2 cm but was otherwise normal.
There was no associated mass effect or vasogenic
edema present on this study. Electroencephalog-
raphy (EEG) was also normal. The differential di-
agnosis at this time included hemorrhagic stroke,
or neoplasm. MRI of the brain with and without
contrast was ordered for further evaluation and
subsequently demonstrated a cavernous mal-
formation involving the right sub-insular region,
putamen, and external capsule with evidence of
previous hemorrhages (Image 1). This localization
of the lesion was thought to be consistent with the
contralateral choreiform movements of the patient.
Neurosurgery was consulted and recommended
non-surgical symptomatic management due to the
location of the lesion and risks of surgery.
The patient was initially started on haloperidol
5mg QID with minimal response. She was subse-
quently switched from haloperidol to olanzapine
2.5mg BID and the dose was later increased to
5mg BID. Additionally, tetrabenazine 12.5mg TID
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