Successful long-term deep brain stimulation for hemichorea—hemiballism in a patient with diabetes

Case report

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✓ The authors report a case of hemichorea—hemiballism (HC-HB) that was successfully treated using deep brain stimulation (DBS). A 65-year-old right-handed man exhibited a sudden onset of right HC-HB without a diabetic coma. At admission T1-weighted magnetic resonance (MR) images revealed a high-intensity signal in the left striatum, contralateral to the patient's involuntary movements.

The HC-HB continued for 5 months after onset of the condition despite medical treatment and a decreased intensity of the signal on T1-weighted MR images.

The patient underwent placement of a quadripolar DBS electrode in the left thalamus, including the left ventral oralis (VO) anterior and posterior nuclei (the VO complex). Postoperatively, the right-sided HC-HB disappeared rapidly during electrical stimulation and there were no neurological deficits.

The authors demonstrate that DBS can be an effective treatment for medically refractory HC-HB. This is the first case of HC-HB that has been successfully treated with DBS.

Article Information

Address reprint requests to: Naoki Nakano, M.D., Department of Neurosurgery, Kinki University School of Medicine, 377–2, Ohnohigashi, Osaka-sayama, Osaka, 589–8511, Japan. email: nakano@neuro-s.med.kindai.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Serial unenhanced CT scans (A and B) and MR images (C–J) of the brain. Two months after onset of HC-HB, a plain CT scan reveals highly attenuated areas, a T1-weighted MR image (C) depicts strong high-intensity signals, and a T2-weighted MR image (G) demonstrates heterogeneous high-intensity signals—all in the left striatum. Three months after symptom onset, a plain CT scan (B) reveals highly attenuated areas, a T1-weighted MR image (D) depicts high-intensity signals, and a T2-weighted MR image (H) demonstrates heterogeneous isointense and slightly high intensity signals—all in the left striatum. Four months after onset, a T1-weighted MR image (E) depicts slightly high intensity signals, and a T2- weighted MR image (I) demonstrates heterogeneous slightly high intensity signals in the left striatum. Five months after onset, the patient underwent implantation of a DBS system. At that time a T1-weighted MR image (F) demonstrated slightly high intensity signals, and the T2-weighted MR image (J) revealed heterogeneous slightly high intensity signals in the left striatum. The lead tip of the DBS electrode appears as a round low signal intensity in the left thalamus on the T1-weighted image (F).

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    Left: Postoperative axial T1-weighted image demonstrating the lead tip of the DBS electrode in the thalamus including the ventralis oralis posterior nucleus (Vop) and the ventralis oralis anterior nucleus (Voa). The round low signal represents the lead tip of the DBS electrode. Center: Magnification of the MR image shown in the left panel. Right: Illustration from the Schaltenbrand—Wahren atlas (2 mm dorsal to the AC—PC line) showing the thalamus. The area corresponds to that seen on the postoperative T1-weighted image. From Schaltenbrand G, Wahren W. Atlas for Stereotaxy of the Human Brain, ed 2. Stuttgart: Thieme, 1997. Plate 53. Reprinted with permission.

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    Left: Postoperative sagittal T1-weighted MR image demonstrating an area of low signal intensity as the quadripolar electrode is placed in the thalamus including the ventralis oralis posterior nucleus and the ventralis oralis anterior nucleus. The four round low signal intensities indicate lead tips of the quadripolar electrode. Right: Illustration from the Schaltenbrand—Wahren atlas (14 mm lateral to the middle of the AC—PC line) showing the thalamus. The area corresponds to that observed on the postoperative T1-weighted image. From Schaltenbrand G, Wahren W. Atlas for Stereotaxy of the Human Brain, ed 2. Stuttgart: Thieme, 1997. Plate 44. Reprinted with permission.

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