The treatment of persistent vascular hemidystonia-hemiballismus with unilateral GPi deep brain stimulation.

摘要

We describe a case of a severe refractory hemidystonia-hem-iballismus resulting from hemorrhage of the right subthala-mic nucleus, which was managed with unilateral globus pallidus internus (GPi) deep brain stimulation (DBS). A 56-year-old man with a history of hypertension presented with a sudden onset of headache, left hemiparesis, and dysarthria. A brain computed tomography (CT) scan showed a small focal hematoma in the right pons, midbrain, and sub-thalamic region. The hemiparesis and dysarthria improved over several days, although not to normality. Four days after presentation, he started to notice left sustained twisting of the wrist, posturing of the arm, held in extension, and sudden flinging movements of the whole arm. This progressed over weeks to reach a stable but disabling level that affected his balance whilst walking, and which prevented him from performing bimanual tasks since the left arm would suddenly deviate outwards. He underwent inpatient neurorehabilitation and was discharged home 1 month later, but continued to have severe ballistic movements despite maximum tolerated medication including tetrabenazine (37.5 mg/tds), haloperidol (3 mg/tds), orphenadrine (50 mg/tds), and botulinum toxin (500 U to left pectoralis). The arm was prone to frequent trauma due to uncontrollable movements. After 3 years of unsuccessful medical therapy, he was referred for functional neurosurgery and underwent multidisciplinary evaluation for DBS.