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  • Pallidal Deep Brain Stimulation and Intraoperative Neurophysiology for Treatment of Post-Stroke Hemiballism

    Final Number:

    Adolfo Ramirez-Zamora MD; Youngwon Youn BA; Sameah A. Haider MD, MBA; Eric Molho MD; Julie G. Pilitsis MD PhD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Deep brain stimulation (DBS) is an established therapy for a variety of refractory movement disorders including Parkinson’s disease, Dystonia and essential tremor. Movement disorders after strokes are uncommon, but post-stroke dystonia and hemiballismus have been reported (Mehanna et al. 2013). Hemiballism commonly resolves spontaneously but in rare occasions remains severe or refractory to medications. In this report, we examine a case of refractory hemichorea-hemiballismus (HC-HB) that developed secondary to a thalamic cerebral infarction and report the clinical outcome at 16 months as well as intraoperative neurophysiology during DBS in the globus pallidus internus (GPi).

    Methods: The patient is a 53-year-old woman presenting with insidious onset, progressive, left arm abnormal involuntary movements starting in her 30s after she suffered a right thalamic, small vessel disease cerebral infarction. Due to the severity of her disabling symptoms over the following decades, she underwent unilateral GPi-DBS. Single-unit neuronal activity recordings in the GPi were obtained using microelectrodes during surgery.

    Results: At 16 months follow up, she had marked improvement in her symptoms with a near complete resolution of hemiballism (video). Comparison of GPi firing frequencies between our patient and that of patients with Parkinson’s disease (PD) and generalized dystonia revealed that HC-HB GPi frequencies were significantly lower than that of both PD and Dystonia (both p<0.001) Figure 1. Additionally, the average GPi rate of 16.00 ± 3.18 Hz was lower in our patient compared with previous reports [46.1 ±29.2 Hz (Oyama et al 2014), 33.7± 21.2 Hz (Vitek et al 1999), and 30±5 Hz (Suarez et al 1997)].

    Conclusions: We report the successful treatment of medically refractory HC-HB with unilateral GPi DBS secondary to a thalamic stroke and provide additional brain neurophysiologic data in this rare syndrome. The excellent clinical outcome highlights the potential benefit of DBS in patients with secondary HC-HB despite long duration of symptoms.

    Patient Care: Our research highlights the potential benefit of Deep Brain Stimulation in patients with medically refractory post-stroke movement disorders.

    Learning Objectives: To understand the effect of GPi-DBS in patients with medically refractory post-stroke hemichorea-hemiballism

    References: Mehanna R, Jankovic J. Movement disorders in cerebrovascular disease. Lancet Neurol. 2013;12(6):597-608. Oyama G, Maling N, Avila-Thompson A, Zeilman PR, Foote KD, Malaty IA, Rodriguez RL, Okun MS. Rescue GPi-DBS for a Stroke-associated Hemiballism in a Patient with STN-DBS. Tremor Other Hyperkinet Mov. 4;4. pii: tre-04-214-4855-1, 2014. Vitek JL, Chockkan V, Zhang JY, et al. Neuronal activity in the basal ganglia in patients with generalized dystonia and hemiballismus. Ann Neurol. 1999;46:22–35. Suarez JI, Metman LV, Reich SG, Dougherty PM, Hallett M, Lenz FA. Pallidotomy for hemiballismus: efficacy and characteristics of neuronal activity. Ann Neurol. 1997;42(5):807-11.

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