RESIDENT & FELLOW SECTION Teaching Video NeuroImages: Delayed hemibody myorhythmia and palatal myoclonus after vertebrobasilar stroke Luı́sa Panadés-de Oliveira, MD, Antonio Méndez-Guerrero, MD, Roberto López-Blanco, MD, Elena Salvador Álvarez, MD, Juan Ruiz Morales, MD, and Jesús González de la Aleja, PhD ® Neurology 2018;90:e542-e543. doi:10.1212/WNL.0000000000004924 Correspondence Dr. Méndez-Guerrero mendezguerrero. antonio@gmail.com Figure 1 Brain MRI shows acute vertebrobasilar stroke Axial T2-weighted brain MRI obtained upon first admission reveals hyperintense lesions in right occipital lobe, thalamus (A) and midbrain (B), and left pons (C), indicated by arrowheads. These areas correspond to a high signal on the diffusion-weighted imaging (D–F) and a low signal in apparent diffusion coefficient map (not showed), confirming an acute infarction in vertebrobasilar territory. MORE ONLINE A 40-year-old woman with well-controlled HIV infection had a vertebrobasilar stroke secondary to endocarditis by Coxiella burnetii (figure 1), with left hemiparesis remaining. Five months later, the patient visited the emergency department complaining of a subacute onset of involuntary movements on her left hemibody. An examination revealed quasirhythmic slow movements at 2–3 Hz affecting the inferior facial musculature, the soft palate, and the left Video links.lww.com/WNL/A115 Teaching Slides: links.lww.com/WNL/A184 From the Neurology Department (L.P.-d.O., A.M.-G., R.L.-B., J.R.M., J.G.d.l.A.), Movement Disorders Section (A.M.-G.), Radiology Department, Neuroradiology Section (E.S.Á.), and Neurology Department, EEG-Epilepsy Section (J.G.d.l.A.), Healthcare Research Institute (R.L.-B.), Hospital Universitario 12 de Octubre, Madrid, Spain. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. e542 Copyright © 2018 American Academy of Neurology Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Figure 2 Inferior olivary nucleus hypertrophy and illustration of the Guillain-Mollaret triangle limbs. These movements were present at rest and worsened with voluntary activity (video, http://links.lww.com/WNL/ A115). EEG and CSF tests were normal, including PCR for Tropheryma whipplei, since it is a treatable cause of involuntary rhythmic slow movements. A brain MRI showed hypertrophic olivary degeneration (figure 2), excluding new lesions. These findings are suggestive of hemimyorhythmia with palatal myoclonus.1 Trials with adequate doses of tetrabenazine, clonazepam, and trihexyphenidyl were unsuccessful. Author contributions Luı́sa Panadés-de Oliveira: acquisition of data, drafting of the original manuscript. Antonio Méndez-Guerrero: study concept and design, drafting of the manuscript, critical revision of the manuscript. Roberto López-Blanco: acquisition of data, drafting of the manuscript, drawing the cartoon, critical revision of the manuscript. Elena Salvador Álvarez: preparation of image, neuroradiology interpretation. Juan Ruiz Morales: history and examination of patient, critical revision of the manuscript. Jesús González de la Aleja: analysis and interpretation of EEG, critical revision of the manuscript for important intellectual content. Acknowledgment The authors thank the patient and her family. Study funding No targeted funding reported. An axial T2-weighted MRI at the level of the medulla oblongata was unremarkable at first admission (arrowhead in A). One year later, T2-weighted MRI reveals a right inferior olivary nucleus hypertrophy (arrowhead in B). (C) Illustration of anatomic pathways implicated in the pathogenesis of myorhythmia and palatal myoclonus in our patient. Dashed arrows indicate the dentato-rubro-olivary and dentato-thalamo-cortical tracts. Asterisks indicate the insults in our patient affecting the right thalamus and the dentato-rubro pathway at the level of the left upper pons. The inferior olivary nucleus, colored blue, represents right hypertrophic olivary degeneration. Neurology.org/N Disclosure The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures. Reference 1. Baizabal-Carvallo JF, Cardoso F, Jankovic J. Myorhythmia: phenomenology, etiology, and treatment. Mov Disord 2015;30:171–179. Neurology | Volume 90, Number 6 | February 6, 2018 Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. e543 Teaching Video NeuroImages: Delayed hemibody myorhythmia and palatal myoclonus after vertebrobasilar stroke Luísa Panadés-de Oliveira, Antonio Méndez-Guerrero, Roberto López-Blanco, et al. Neurology 2018;90;e542-e543 DOI 10.1212/WNL.0000000000004924 This information is current as of February 5, 2018 Updated Information & Services including high resolution figures, can be found at: http://n.neurology.org/content/90/6/e542.full.html References This article cites 1 articles, 0 of which you can access for free at: http://n.neurology.org/content/90/6/e542.full.html##ref-list-1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Dystonia http://n.neurology.org//cgi/collection/dystonia MRI http://n.neurology.org//cgi/collection/mri Myoclonus http://n.neurology.org//cgi/collection/myoclonus Status epilepticus http://n.neurology.org//cgi/collection/status_epilepticus Stroke in young adults http://n.neurology.org//cgi/collection/stroke_in_young_adults Permissions & Licensing Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://n.neurology.org/misc/about.xhtml#permissions Reprints Information about ordering reprints can be found online: http://n.neurology.org/misc/addir.xhtml#reprintsus Neurology ® is the official journal of the American Academy of Neurology. 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