Objective: To describe the case of a 31-year-old man with partially treated cryptococcal meningitis complicated by acute hemiballismus treated with unilateral radiofrequency pallidotomy.

Background: Hemiballismus has classically been described as a result of vascular or metabolic insults to basal ganglia. Infectious causes are rare and were mostly reported in patients with HIV-related opportunistic infections. Treatment options include dopaminergic blockers or VMAT2 inhibitors. Radiofrequency pallidotomy has been used to treat hemiballismus in medically refractory patients.

Method: Case Report.

Results: A 31-year-old immune-competent right-handed man with a history of schizophrenia and substance abuse presented to Vanderbilt University Medical Center with altered mental status requiring intubation and sedation. He was diagnosed with cryptococcal meningitis with cerebritis and multiple abscesses involving the bilateral basal ganglia. Abnormal, disabling right-sided movements began during his hospitalization; eventually leading to hemichorea-hemiballismus that required restraints to avoid injuries. He was started on escalating doses of tetrabenazine and haloperidol, with only mild improvement in his symptoms, and side-effects including sedation, copious diarrhea and continued altered mentation. The patient underwent an urgent left stereotactic pallidotomy under general anesthesia. The posterior-ventral pallidum was targeted and intraoperative test stimulation was used to avoid capsular lesioning. Three lesions (60 seconds at 80°C) were delivered to posteroventral globus pallidus interna (AC-PC: AP = +2.1mm, ML = -19.0mm, SI = -3.2 & -6.2 & -9.2mm).  His hemiballismus improved immediately after surgery and his medications were reduced. These movements remained dampened six weeks after surgery; he was able to use his right side, ambulate independently, and was no longer taking tetrabenazine. He did have mild dysarthria on examination and complained of mild right leg discomfort, possibly related to sensory changes from the pallidotomy, neurologic damage from the meningitis, or a musculoskeletal issue.

Conclusion: Stereotactic radiofrequency pallidotomy is an effective treatment of hemichorea-hemiballismus caused by cryptococcal meningitis and, in general, remains an attractive surgical option for medication-resistant hemiballismus patients.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/acute-medically-refractory-hemichorea-hemiballismus-treated-by-unilateral-pallidotomy-a-case-report/