Successful intravenous thrombolysis in a stroke patient with hemiballism.

INTRODUCTION

Hemiballism (HB) is a relatively rare hyperkinetic disorder commonly caused by an acute stroke. Such patients usually receive symptomatic therapy with limited effect. We report the case of an acute stroke patient with HB who was successfully treated with intravenous recombinant tissue plasminogen activator (rtPA).

CASE REPORT

A 67-year-old man with a history of hypertension and ischemic coronary heart disease presented in the emergency room 85 minutes after sudden onset of involuntary coarse flinging movements of the left arm and leg. Neurological investigation revealed oromandibular dyskinesia; left blepharospasm; dyskinetic movements of the head and neck; dysarthria; and forceful, jerky, irregular, flinging, large-amplitude involuntary movements involving his left arm and left leg. Initial brain computed tomography showed only mild confluent periventricular hypodensities in the vicinity of the frontal horns. The calculated National Institutes of Health Stroke Scale score was 1, for dysarthria. The sudden onset of HB, however, suggested an acute stroke and we decided to treat the patient with intravenous rtPA. Thrombolytic therapy with rtPA began 200 minutes after symptom onset, and after the patient's increased arterial blood pressure was resolved. Follow-up examination performed 12 hours after therapy revealed only mild dysarthria; mild ataxia of the left arm, and ataxic gait. Delayed brain computed tomography did not indicate recent ischemia, although a fluid attenuated inversion recovery magnetic resonance imaging sequence revealed high signal intensity lesions in the vicinity of the right putamen and left cerebellar hemisphere. After 1 month, a follow-up examination revealed only mild dysarthria and mild ataxia of the left arm.

CONCLUSIONS

Acute stroke patients with low National Institutes of Health Stroke Scale score, including patients with HB, should be considered as candidates for thrombolytic treatment.