Objective: We present challenges in treatment in a young patient with severe unilateral post-stroke hemichorea-hemiballism in addition to a cerebellar outflow tract tremor affecting his dominant side.

Background: Post-stroke movement disorders may leave patients with significant residual disability. Hyperkinetic movements like hemichorea-hemiballism (HCHB) while rare, can be medically refractive and particularly challenging to deal with.

Method: N

Results: A 48-year-old right-handed man with a history of hepatitis C, hypertension, cervical myelopathy, peripheral neuropathy, seizures and prior ischemic strokes presented with progressive, unremitting severe right-sided hemichorea-hemiballism with a underlying cerebellar outflow tract tremor secondary to a left thalamic infarct. Physical exam  revealed right-sided hemiparesis more so distally with MRC 2/5 strength in the finger extensors and 4/5 in finger extensors; 5/5 strength in all other muscle groups. In addition a severe right upper extremity hemiballistic, choreo-athetotic tremor with action>postural>resting component was noted. The tremor was medically-refractive and severely disabling, interfering with his ability to perform activities of daily living and participate in rehabilitation. He also had a mild postural tremor in the right leg.G iven the complexity of his post-stroke hyperkinetic disorder and its residual disability impacting his quality of life, a decision was made to proceed with DBS surgery with unilateral (left) ventral intermediate (VIM) nucleus  implantation. The patient has continued to follow with us for over 15 years and is doing well. He is independent with his activities of daily living. His residual action and resting tremor of the right upper extremities has continued to respond well to increments in his amplitude and pulse width.

Conclusion: Post-stroke HCHB can be a challenging entity for both the patient and the clinician to deal with. While most cases are seen in the acute phase and spontaneously resolve or decrease in intensity, when the ballistic movements are persistent and medically refractory, surgical treatment such as DBS should be strongly considered. There is no clear consensus currently on a stereotactic target for these atypical tremors. While our patient responded well to a traditional target of the Vim nucleus, there are a few reports of patient’s with similar tremor syndromes with more of a dystonic component benefitting from DBS targeting the GPi and DRTt.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/deep-brain-stimulation-responsive-hemichorea-hemiballism/