A combined pattern of movement disorders resulting from posterolateral thalamic lesions of a vascular nature: a syndrome with clinico-radiologic correlation

Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management

Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.

Post-Thalamic Stroke Movement Disorders: A Systematic Review

BACKGROUND

After a stroke, movement disorders are rare manifestations mainly affecting the deep structures of the brain like the basal ganglia (44%) and thalamus (37%), although there have been case studies of movement disorders in strokes affecting the cerebral cortex also.

SUMMARY

This review aims to delineate the various movement disorders seen in association with thalamic strokes and tries to identify the location of the nuclei affected in each of the described movement disorders. Cases were identified through a search of PubMed database using different search terms related to post-thalamic stroke movement disorders and a secondary search of references of identified articles. We reviewed 2,520 research articles and only 86 papers met the inclusion criteria. Cases were included if they met criteria for post-thalamic stroke movement disorders. Case-cohort studies were also reviewed and will be discussed further. Key Messages: The most common post-stroke abnormal movement disorder reported in our review was dystonia followed by hemiataxia. There was a higher association between ischaemic stroke and movement disorder. Acute onset movement disorders were more common than delayed. The posterolateral thalamus was most commonly involved in post-thalamic stroke movement disorders.

The anatomical basis of upper limb dystonia: lesson from secondary cases

Upper limb dystonia is a focal dystonia that may affect muscles in the arm, forearm and hand. The neuroanatomical substrates involved in upper limb dystonia are not fully understood. Traditionally, dysfunction of the basal ganglia is presumed to be the main cause of dystonia but a growing body of evidence suggests that a network of additional cortical and subcortical structures may be involved. To identify the brain regions that are affected in secondary upper limb dystonia may help to better understand the neuroanatomical basis of the condition. We considered only patients with focal upper limb dystonia associated with a single localized brain lesion. To identify these patients, we conducted a systematic review of the published literature as well as the medical records of 350 patients with adult-onset dystonia seen over past 15 years at our movement disorder clinic. The literature review revealed 36 articles describing 72 cases of focal upper limb dystonia associated with focal lesions. Among patients at our clinic, four had focal lesions on imaging studies. Lesions were found in multiple regions including thalamus (n = 39), basal ganglia (n = 17), cortex (n = 4), brainstem (n = 4), cerebellum (n = 1), and cervical spine (n = 7). Dystonic tremor was not associated with any particular site of lesion, whereas there was a trend for an inverse association between task specificity and thalamic involvement. These data in combination with functional imaging studies of idiopathic upper limb dystonia support a model in which a network of different regions plays a role in pathogenesis.

3D texture analysis reveals imperceptible MRI textural alterations in the thalamus and putamen in progressive myoclonic epilepsy type 1, EPM1

Progressive myoclonic epilepsy type 1 (EPM1) is an autosomal recessively inherited neurodegenerative disorder characterized by young onset age, myoclonus and tonic-clonic epileptic seizures. At the time of diagnosis, the visual assessment of the brain MRI is usually normal, with no major changes found later. Therefore, we utilized texture analysis (TA) to characterize and classify the underlying properties of the affected brain tissue by means of 3D texture features. Sixteen genetically verified patients with EPM1 and 16 healthy controls were included in the study. TA was performed upon 3D volumes of interest that were placed bilaterally in the thalamus, amygdala, hippocampus, caudate nucleus and putamen. Compared to the healthy controls, EPM1 patients had significant textural differences especially in the thalamus and right putamen. The most significantly differing texture features included parameters that measure the complexity and heterogeneity of the tissue, such as the co-occurrence matrix-based entropy and angular second moment, and also the run-length matrix-based parameters of gray-level non-uniformity, short run emphasis and long run emphasis. This study demonstrates the usability of 3D TA for extracting additional information from MR images. Textural alterations which suggest complex, coarse and heterogeneous appearance were found bilaterally in the thalamus, supporting the previous literature on thalamic pathology in EPM1. The observed putamenal involvement is a novel finding. Our results encourage further studies on the clinical applications, feasibility, reproducibility and reliability of 3D TA.

Movement disorders in cerebrovascular disease

Movement disorders can occur as primary (idiopathic) or genetic disease, as a manifestation of an underlying neurodegenerative disorder, or secondary to a wide range of neurological or systemic diseases. Cerebrovascular diseases represent up to 22% of secondary movement disorders, and involuntary movements develop after 1-4% of strokes. Post-stroke movement disorders can manifest in parkinsonism or a wide range of hyperkinetic movement disorders including chorea, ballism, athetosis, dystonia, tremor, myoclonus, stereotypies, and akathisia. Some of these disorders occur immediately after acute stroke, whereas others can develop later, and yet others represent delayed-onset progressive movement disorders. These movement disorders have been encountered in patients with ischaemic and haemorrhagic strokes, subarachnoid haemorrhage, cerebrovascular malformations, and dural arteriovenous fistula affecting the basal ganglia, their connections, or both.

Pure hemi-chorea resulting from an acute phase of contralateral thalamic lacunar infarction: a case report

Background

Thalamic lesions give rise to a variety of clinical syndromes such as pure sensory stroke, ataxic hemiparesis, and rarely involuntary movements including chorea. Generally and classically, lacunar infarction in the subthalamic nucleus has been regarded as the lesion mainly responsible for hemi-chorea and hemi-ballismus, on the basis of previous anatomical studies.

Case Presentation

This report describes the case of an 81-year-old man who developed sudden-onset pure hemi-chorea in the right limbs resulting from an acute phase of left thalamic lacunar infarction detected on a diffusion-weighted image (DWI) in an MRI study. The patient had no other neurological symptoms such as ataxic hemiparesis and sensory disturbance. A single-photon emission computed tomography (SPECT) study using the ^99mTc-ECD Patlak plot method demonstrated significant perfusional asymmetry between the right and left thalami (p = 0.0035), consistent with the left thalamic lesion on DWI.

Conclusion

It is speculated that this perfusional asymmetry, in particular the hypoperfusion in the left thalamus, detected by SPECT might play the most important role in the contralateral pure hemi-chorea as a rare neurological manifestation in this case.

Rehabilitation of movement disorders11A commercial party with a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit upon the author or one or more of the authors. Elovic is on the advisory board and speaker’s bureau of Allergan

This self-directed learning module highlights several movement disorders. These include dystonia, chorea, tremors, and myoclonus. A description of the clinical presentation and associated disease processes is presented. Although the discussion on treatment focuses on pharmacologic intervention, surgical options are presented when appropriate. Other movement disorders (ie, parkinsonism) are discussed elsewhere in the Study Guide.

OVERALL ARTICLE OBJECTIVES

(a) To define the various symptoms and etiologies of dystonia; (b) to define chorea and its treatment; (c) to define tremors, including associated neurologic disorders, plus pharmacologic and potential surgical interventions; and (d) to describe the symptoms, classification, and treatment of primary and secondary myoclonus.

Intracortical inhibition is reduced in a patient with a lesion in the posterolateral thalamus

We describe a patient who developed a complex movement disorder following an ischemic lesion in the right posterolateral thalamus. Transcranial magnetic stimulation showed a shortening of the cortical silent period and deficient cortico-cortical inhibition using paired magnetic pulses on the affected side, indicating reduced effectiveness of intracortical inhibitory mechanisms.

Complex movement disorders following bilateral paramedian thalamic and bilateral cerebellar infarcts

Complex movement disorders (CMD; including tremor, dystonias, choreoatheosis, and myoclonus) following infarcts in the posterior and posterolateral thalamic nuclei have been reported. This case of a 59-year-old man who developed CMD following bilateral paramedian and bilateral cerebellar infarcts illustrates the lack of anatomic specificity and the diverse pathophysiology which may underlie CMD.