Images in… Azam S Tolla ‍ ‍,1,2 Luke T Schichtel,3 Ayman Alboudi,2 Audrey K Sanders2 1 Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA 2 Hauenstein Neurosciences, Mercy Health Saint Mary’s, Grand Rapids, Michigan, USA 3 Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA Correspondence to Dr Azam S Tolla; ​tollaaza@​msu.e​ du Accepted 21 April 2020 © BMJ Publishing Group Limited 2020. No commercial re-­use. See rights and permissions. Published by BMJ. To cite: Tolla AS, Schichtel LT, Alboudi A, et al. BMJ Case Rep 2020;13:e234861. doi:10.1136/bcr-2020234861 Description A 90-­year-­old woman presented with choreoathetosis (video 1) involving her right upper and lower extremities beginning 3 days prior to presentation. Her choreoathetosis worsened with distraction but improved with purposeful movements (eg, writing her name). Further neurological examination revealed mild dysarthria and right upper motor neuron facial palsy. A brain MRI showed an infarction involving the left internal capsule and the basal ganglia (figure 1) in the anterior choroidal artery (AchA) territory with a Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification of stroke of undetermined aetiology. The prevalence of AchA ischaemic stroke is low, accounting for approximately 3% of all ischaemic strokes.1 The AchA is a direct branch arising from the internal carotid artery and infarcts in this territory raise the suspicion of a possible cardioembolic event. Its deep branches typically supply the posterior limb of the internal capsule, optic radiations and portions of the caudate and globus pallidus (figure 2).1 2 AchA strokes most commonly present as a triad of hemiparesis, hemianaesthesia and hemianopia but a wide variety of other clinical manifestations have been reported including abnormal movements presenting as new-­onset parkinsonism, one example of tonic spasms, and a recent report Figure 1 (A) Fluid-­attenuated inversion recovery (FLAIR) sequence showing significant leukoaraiosis. (B) FLAIR sequence revealing infarct lesion (red oval). (C) and (D) Diffusion weighted imaging sequence showing restricted diffusion involving the left internal capsule and the basal ganglia. Figure 2 (A) Vascular supply (coronal view). (B) Vascular supply (axial view). This is a commissioned artwork by Azam S Tolla and retains the rights to it. of a posterior variant of alien limb syndrome.3–5 To our knowledge, our patient is the first example of choreoathetosis in the setting of AchA ischaemic stroke. Movement disorders are a rare complication of both ischaemic and haemorrhagic strokes, which can present as either hyperkinetic or hypokinetic movements depending on the region of brain involved and the individual’s age.6 Dystonia, hemichorea, hemiballismus, tremor, myoclonus, athetosis, asterixis and parkinsonism have all been described.6 Overall, the basal ganglia is the most common location causing stroke-­related movement disorders. Post-­stroke movement disorders generally resolve within 2 weeks in 50% of the population.7 Infarcts within the deep thalamic branches arising from the posterior cerebral artery (PCA) as well as the deep branches from the middle cerebral artery (MCA) are typically implicated in these stroke presentations. However, it may be possible that AchA infarcts are an under-­recognised cause, which raises important clinical questions regarding the actual stroke aetiology, whether it is small-­vessel Tolla AS, et al. BMJ Case Rep 2020;13:e234861. doi:10.1136/bcr-2020-234861 1 BMJ Case Rep: first published as 10.1136/bcr-2020-234861 on 11 May 2020. Downloaded from http://casereports.bmj.com/ on April 18, 2024 by guest. Protected by copyright. Anterior choroidal artery infarct presenting as right hemichoreoathetosis Images in… Contributors AST contributed to the conception and design, data collection, drafting and revision of manuscript. LTS and AA contributed to the interpretation of data and manuscript review. AKS contributed to the manuscript review. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-­for-­profit sectors. Competing interests None declared. video 1 Right hemichoreoathetosis secondary to anterior choroidal artery infarct. Learning points ►► Movement disorders are a rare complication of stroke accounting for less than 1% of all cases. ►► Half of such cases spontaneously resolve within 2 weeks of presentation. ►► Anterior choroidal artery infarct may be an under-­recognised cause of stroke-­related movement disorders. ►► Dopamine antagonists may be used for symptomatic management. disease (as would be the case of deep branch involvement of MCA or PCA) or a cardioembolic event (AchA involvement). So, paying close attention to infarct territory is essential in making Patient consent for publication Obtained. Provenance and peer review Not commissioned; externally peer reviewed. ORCID iD Azam S Tolla http://​orcid.​org/​0000-​0003-​1211-​3793 References 1 Palomeras E, Fossas P, Cano AT, et al. Anterior choroidal artery infarction: a clinical, etiologic and prognostic study. Acta Neurol Scand 2008;118:42–7. 2 Derflinger S, Fiebach JB, Böttger S, et al. The progressive course of neurological symptoms in anterior choroidal artery infarcts. Int J Stroke 2015;10:134–7. 3 Morgenstern LB, Hankins LL, Grotta JC. Anterior choroidal artery aneurysm and stroke. Neurology 1996;47:1090–2. 4 Yu J, Xu N, Zhao Y, et al. Clinical importance of the anterior choroidal artery: a review of the literature. Int J Med Sci 2018;15:368–75. 5 Russo M, Carrarini C, Dono F, et al. Posterior variant of alien limb syndrome with sudden clinical onset as Self-­Hitting associated with thalamic stroke. Case Rep Neurol 2020;12:35–9. 6 Handley A, Medcalf P, Hellier K, et al. Movement disorders after stroke. Age Ageing 2020;38:260–6. 7 Ghika-­Schmid F, Ghika J, Regli F, et al. Hyperkinetic movement disorders during and after acute stroke: the Lausanne stroke Registry. J Neurol Sci 1997;146:109–16. Copyright 2020 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit https://www.bmj.com/company/products-services/rights-and-licensing/permissions/ BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ►► Submit as many cases as you like ►► Enjoy fast sympathetic peer review and rapid publication of accepted articles ►► Access all the published articles ►► Re-use any of the published material for personal use and teaching without further permission Customer Service If you have any further queries about your subscription, please contact our customer services team on +44 (0) 207111 1105 or via email at support@bmj.com. Visit casereports.bmj.com for more articles like this and to become a Fellow 2 Tolla AS, et al. BMJ Case Rep 2020;13:e234861. doi:10.1136/bcr-2020-234861 BMJ Case Rep: first published as 10.1136/bcr-2020-234861 on 11 May 2020. Downloaded from http://casereports.bmj.com/ on April 18, 2024 by guest. Protected by copyright. the proper diagnosis. Treatment with dopamine antagonists can provide symptomatic relief to patients if spontaneous resolution is not achieved. In the acute setting, our patient was started taking risperidone. At 1-­month follow-­up, she still had persistent symptoms and was switched to deutetrabenazine. Unfortunately, the patient has only achieved minimal relief to date.