Fatal Hemichorea Following Sub‐Thalamic Nucleus Hemorrhage in Stroke Patient

Objective To describe a case of punctate right sub‐thalamic nucleus hemorrhage leading to severe, medically refractory hemichorea and hemiballism. Background Hemichorea and other similar unilateral movement disorders are rare in the general population, and rarer still when further subdivided by etiology. Hemichorea following stroke—either hemorrhagic or ischemic—is a symptom following less than 0.5% of stroke patients. While rare, it can be exceedingly difficult to successfully manage, and may be a significant cause of long‐term morbidity or mortality in those with otherwise minimal stroke burden. This case aims to illustrate that principle with a small hemorrhagic lesion that was profoundly symptomatic, ultimately leading to the patient's death. Design/Methods N/A Results Our patient is a 77 year old male with a history of hyperlipidemia, hypertension and remote tobacco use who presented for acute‐onset right upper and lower extremity incoordination. On presentation, he was noted not to be weak or ataxic, but rather to have high‐velocity, high‐amplitude uncontrollable movements of the right hemibody. CT of the head revealed a punctate, circular focus of hemorrhage in the right sub thalamic nucleus with mild circumferential edema expending into the crus of the right midbrain. CTA was unremarkable; MRI confirmed the location of the hemorrhage. Multiple medications including numerous benzodiazepines, antipsychotics, mood stabilizers and anticholinergics were trialed over a nearly two‐week period to control his movements with limited effect. Despite multiple attempts to optimize wound care, his left upper and lower extremity became severely denuded and excoriated secondary to friction injury due to his uncontrolled movements. This lead to hypovolemia and shock, requiring re‐admission to the ICU. Ultimately, the patient's family elected for a transition to comfort care due to mounting consequences from the injuries and physiologic strain accrued from his hemichorea, and the patient passed away shortly thereafter. Conclusions While rare, and often managed without significant difficulty, refractory hemichorea and hemiballism due to infarction—ischemic or hemorrhagic—can be potential fatal and is an under‐represented consequence of stroke.