Hemichorea Chronic

Associated

with

Subdural

Ipsilateral

Hematoma

Case Report— — Masami YOSHIKAWA, Mitsuo YAMAMOTO, Kenji SHIBATA, Keiji OHTA, Yasushi KAMITE, Masaru TAKAHASHI, Yasutaka SHIMIZU*, Shinji OHBA**, Satoshi KUWABARA** and Tohru UOZUMI Departments of Neurosurgery **Department of Neurosurgery

and *Neurology, Matsue Red Cross Hospital, Matsue; , Hiroshima University School of Medicine, Hiroshima

Abstract Left-sided hemichorea developed suddenly in a 73-year-old male. Computed tomography revealed a left subdural hematoma (SDH) and infarction in the right corona radiata and temporo-occipital region. Hemichorea subsided completely after removal of the SDH. Postoperative single photon emis sion computed tomography with technetium-99m-hexamethyl-propyleneamine oxime revealed a global low-perfusion area in the right cerebral hemisphere. Right carotid angiography demonstrated severe stenosis of the trunk of the right middle cerebral artery. The cerebral blood flow in the right cerebral hemisphere had probably already decreased to nearly the critical level and was reduced further by the left SDH, inducing the left-sided hemichorea due to dysfunction of the right cerebral hemisphere. This case shows that when hemichorea ipsilateral to a SDH is present, it is important to ascertain whether there is a pre-existing ischemic lesion in the contralateral cerebral hemisphere, partic ularly in the basal ganglia, thalamus, or corona radiata. Key words:

hemichorea,

subdural

hematoma,

Introduction

cerebral

Author's

November present

20,

address:

stant, involuntary, irregular, purposeless, and non rhythmic movements of the left upper and lower ex tremities. These choreiform movements disappeared during sleep and were aggravated by psychological stress or resting posture. No similar movements were detected in the right upper and lower extremities or in the face. He was fully awake and alert. He denied any history of head trauma, or alcohol or drug abuse. Tactile and pain sensation were slightly im

Report

1991;

ischemia

per and lower extremities. Blood pressure was 140/ 72 mmHg and a general physical examination was normal. Neurological examination revealed con

A 73-year-old male complaining of mild headache was admitted in February, 1990. Neurological ex amination showed no abnormalities. Computed tomographic (CT) scans revealed bilateral subdural effusion and a small infarct in the right corona radiata (Fig. 1). Mild headache was resolved by in travenous administration of glycerol over several days. Received

flow,

He was readmitted in July, 1990, complaining of acute onset of involuntary movements in the left up

The etiology of chorea varies widely,') but chorea as sociated with chronic subdural hematoma (SDH) is rare. 1,3,10,15,23) We report a patient with acute hemichorea associated with ipsilateral chronic SDH. Case

blood

Accepted

M. Yoshikawa, M.D., Hiroshima, Japan.

March

paired on the left weakness or sensory and lower extremities.

body. There was no motor disturbance in the right upper Deep tendon reflexes were in

19, 1992

Department

of Neurosurgery,

Hiroshima

University

School

of Medicine,

(99mTc-HMPAO) demonstrated a global low-perfu sion area in the right cerebral hemisphere (Fig. 3). Right carotid angiograms revealed severe stenosis of the trunk of the right middle cerebral artery (Fig. 4). Magnetic resonance (MR) images clearly showed cerebral infarcts in the right corona radiata and tem poro-occipital region, and reduced mass effect due to the left chronic SDH, but no lesion in the basal ganglia, thalamus, or brainstem (Fig. 5). The choreiform movements became markedly less after hematoma evacuation and subsided completely in 1 month without medication. He was discharged ambulatory 5 weeks after the operation.

Fig.

1

Precontrast bilateral area

CT subdural

in the right

scan

on

admission,

effusion corona

and

showing

a low-density

radiata.

Fig. 3 Postoperative SPECT scans with 99mTc HMPAO, showing a global low-perfusion area in the right cerebral hemisphere, especial ly in the right central cerebral region. left: Axial view, right: coronal view. Fig. 2

Precontrast a left

CT scans

subdural

the right

corona

mass radiata

on readmission,

showing

and

areas

low-density

in

and temporo-occipital

region.

creased in the left upper and lower extremities. The plantar response was flexor on the right, extensor on the left. CT scans on readmission disclosed a left chronic SDH and infarcts in the right corona radiata and tem poro-occipital region (Fig. 2). The anterior horn of the left lateral ventricle was compressed. The midline structures were slightly shifted to the right. The left sided hemichorea was probably due to dysfunction of the right cerebral hemisphere caused by the left chronic SDH. Approximately 20 ml of hematoma was evacuated through a single burr hole. On the 14th postoperative day, single photon emission CT (SPECT) scans with technetium-99m-hexamethyl-propyleneamine oxime

Fig. 4

Postoperative right carotid arteriogram, show ing a severe stenosis (arrow) of the main trunk of the middle cerebral artery.

Fig. 5

Postoperative infarcts

SE MR

in the

right

images,

showing

corona

radiata

poro-occipital region. found in the basal brainstem.

upper:

cerebral and

tem

No ischemic lesion ganglia, thalamus,

500/25

msec,

lower:

is or

2000/

90 msec.

Discussion Involuntary Parkinsonian16,1;) or choreiform move ments',3,10,15,23) in association with SDH is rare. Table 1 summarizes the six reported cases of choreiform movements associated with chronic SDH. There were two bilateral and four unilateral hematoma cases. Generalized choreiform move ments were observed in two bilateral and in two uni lateral cases. Hemichorea was observed in two

Table

1

Summary

of reported

cases

of choreiform

movement

cases of unilateral hematoma ipsilateral to the SDH. In all six cases, choreiform movements subsided im mediately, or were markedly reduced and resolved completely within 1 month of removal of the hematoma. Hemichorea is a relatively uncommon movement disorder that usually follows an ischernic" 1,12,17) or hemorrhagic21) lesion in the contralateral caudate nucleus or putamen,8) corona radiata,2) thalamus,") or subthalamic nucleus .21)Lesions outside these struc tures may also be associated with hemichorea.s,11.12) However, in Vincent's 23)and our cases, hemichorea ipsilateral to the hematoma was observed. Vincent described a 83-year-old male with a right chronic SDH manifesting as ipsilateral hemichorea. CT scans showed no ischemic or hemorrhagic lesion possibly responsible for the right-sided hemichorea in the left cerebral hemisphere. However, he speculated that the right-sided hemichorea might be due to a pre-ex isting ischemic lesion in the contralateral thalamic or subthalamic areas. In our case, CT scans detected a pre-existing ischemic lesion in the contralateral cerebral hemisphere. Our patient was unusual as a small amount of left SDH had probably caused dysfunction of the right cerebral hemisphere without manifesting localizing signs in the left cerebral hemisphere. Also, there were pre-existing ischemic lesions. Usually, chronic SDHs of 40-60 ml cause no symptoms.") However, some reports4,7'13.19,2°,22) on patients with chronic SDH suggested that: 1) the mean hemispheric cerebral blood flow (CBF) decreased on both the side with hematoma and contralaterally; 2) the CBF reduction was always greater in the putamen and thalamus than in the cortex; and 3) reduced CBF occurred even in patients with only headache and minimal or no brain shift on CT scan (hematoma volume 20-70 ml). We therefore concluded that in our patient the CBF in the right cerebral hemisphere had already decreased to nearly the critical level as suggested by postoperative SPECT with 99-Tc-HMPAO and cerebral angiography. The CBF was reduced further

associated

with

SDH

by the left chronic SDH, inducing the left-sided hemichorea due to dysfunction of the right cerebral hemisphere. The CBF in the left cerebral hemisphere might not have decreased sufficiently to cause local izing sign. This case shows that when hemichorea ipsilateral to a SDH is present, it is important to as certain whether there is a pre-existing ischemic le sion in the contralateral cerebral hemisphere and that a small volume of SDH may cause neurologi cal deficits in a patient with pre-existing ischemic lesion.

elderly

11) 12)

13)

14) 15)

References 1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

Bae SH, Vates TS Jr, Kenton EJ III: Generalized chorea associated with chronic subdural hematomas. Ann Neurol 8: 449-450, 1980 Barinagarrementeria F, Vega F, DelBrutto OH: Acute hemichorea due to infarction in the corona radiata. J Neurol 236: 371-372, 1989 Bean SC, Ladisch S: Chorea associated with a sub dural hematoma in a child with leukemia. J Pediatr 90: 255-256, 1977 Fukuda T, Ikeda Y, Nagai K, Azuma S, Ito H, Miwa T: Examination of senile chronic subdural hema toma: Its relationship to CT findings, intracranial pressure, mean hemispheric cerebral blood flow, and clinical features. Shinkei Gaisho 9: 55-61, 1986 (in Japanese) Gioino GG, Dierssen G, Cooper IS: The effect of sub cortical lesions on production and alleviation of hemiballic or hemichoreic movements. J Neurol Sci 3: 10-36, 1966 Greenhouse A: On chorea, lupus erythematosus, and cerebral arteritis. Arch Intern Med (Chicago) 117: 389-393, 1966 Ikeda K, Kano A, Hayase H, Yamashima T, Ito H, Yamamoto S: Relationship between symptoms of chronic subdural hematoma and hematoma volume or regional cerebral blood flow. Neurol Med Chir (Tokyo) 24: 869-875, 1984 (in Japanese) Jones HR, Baker RA, Kott HS: Hypertensive putaminal hemorrhage presenting with hemichorea. Stroke 16: 130-131, 1985 Kase CS, Maulsby GO, DeJuan E, Mohr JP: Hemichorea-hemiballism and lacunar infarction in the basal ganglia. Neurology (NY) 31: 452-455, 1981 Kotagal S, Shuter E, Horenstein S: Chorea as a manifestation of bilateral subdural hematoma in an

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man.

Arch

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38:

195, 1981

Martin JP: Hemichorea (hemiballismus) without le sions in the corpus Luysii. Brain 80: 1-11, 1957 Martin JP: Choreatic syndromes, in Vinken PJ , Bruyn GW (eds): Handbook of Clinical Neurology , vol 6. Amsterdam, North-Holland, 1968, pp 435-439 Nukui H, Aiba T: Regional cerebral blood flow in pa tients with chronic subdural hematoma . No Shinkei Gaisho 4: 371-382, 1972 (in Japanese) Plum F, Posner JB: The Diagnosis of Stupor and Coma, ed 3. Philadelphia, Davis, 1980, p 123 Saito T, Shimizu Y, Katagiri M, Kowa H, Tazaki Y: Generalized chorea associated with chronic subdural hematoma. Rinsho Shinkeigaku 22: 106-111, 1982 (in Japanese) Samiy E: Chronic subdural hematoma presenting a Parkinsonian syndrome. J Neurosurg 20: 903, 1963 Saris S: Chorea caused by caudate infarction. Arch Neurol 40: 590-591, 1983 Schisano G, Gimino R, Schonauer M: Ematoma sub durale cronico a sintomatologia extrapiramidale acuta. Rass Int Clin Ter 50: 898-901, 1970 Segawa H, Fujie K, Fujimaki T, Morimoto T, Aritake K, Jinbe H, Sano K: Effect of hematoma pressure on cerebral blood flow and function in chronic subdural hematoma, in: Abstracts of the 45th Congress of the Japan Neurosurgical Society . 1986, p 350 (in Japanese) Tanaka A, Yoshinaga S, Kimura M: Xenon-en hanced computed tomographic measurement of cerebral blood flow in patients with chronic subdu ral hematomas. Neurosurgery 27: 554-561, 1990 Thurel MMR, Grenier J: Hémichorée avec hémiballisme: Hémorrhagie limitee au corps de Luys du cote oppose. Rev Neurol (Paris) 79: 502, 1947 Ueda M, Takahashi Y, Ohmiya N, Mikami J, Ito K, Sato H, Matsuoka T, Takeda S, Ohkawara S: Single photon emission CT-findings in chronic subdural hematoma. CT Kenkyu 7: 623-630, 1985 (in Japanese) Vincent FM: Chorea: A late complication of a sub dural hematoma. Neurology (NY) 30: 335-336 , 1980 (letter to the editor)

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to: M. Yoshikawa, Hiroshima Kasumi,

M.D., University

Minami-ku,

Depart School

Hiroshima

Hemichorea associated with ipsilateral chronic subdural hematoma--case report.

Left-sided hemichorea developed suddenly in a 73-year-old male. Computed tomography revealed a left subdural hematoma (SDH) and infarction in the righ...
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