Chorea as a Manifestation of Bilateral Subdural Hematoma in an Elderly Man Suresh Kotagal, MD; Eli Shuter, MD; Simon Horenstein, MD \s=b\ As in a previously described child with unilateral subdural hematoma, bilateral subdural hematoma in the adult can also be associated with reversible chorea. (Arch Neurol 1981;38:195) varied manifestations of chronic r"phe -* subdural hematoma include, others, dementia, headache, hemiparesis, fluctuating level of con¬ sciousness, apathy, stupor, and coma. We describe a patient with chorea, not among subdural hematomata were discovered by computerized tomography. There was sub¬ stantial compression of the lateral ventri¬ cles. Except for a hypodense biconvex zone in the left frontal region, the hematomata were isodense. Closed surgical drainage of the subdural spaces permitted the removal of approximately 80 mL of chocolatecolored fluid from each side. Postoperatively, there was substantial improvement in mental status. The choreoathetoid move¬ ments subsided completely. When exam¬ ined two months after discharge, the patient was cheerful, fully oriented, and walked independently. hitherto described in the adult. REPORT OF A CASE A 73-year-old man had adult-onset dia¬ betes and had undergone left below-knee amputation for peripheral vascular disease with gangrene of the toes. While learning to use a prosthesis, he fell several times, striking his head at least once. During the ensuing three months, he was noted by family members to have become in¬ creasingly confused. He was hospitalized in October 1978. He was disoriented with regard to place and person, and demonstrated right-left confusion and impaired verbal comprehen¬ sion of two-step commands. Speech fluency and naming abilities were normal. Proxi¬ mal and distal portions of both upper extremities exhibited nearly constant choreoathetoid movements that were, in part, responsible for his inability to feed him¬ self. Slow, writhing, supination-pronation movements of the hands were intermin¬ gled with semipurposive movements of the hands and shoulders. Undulating move¬ ments of the tongue were usually present. All motor restlessness subsided during sleep. An abnormal lengthening-short¬ ening reaction manifested as bilateral paratonia was more marked in the lower extremities. Released perioral and grasp reflexes were evident. The neck was sup¬ ple. There was impaired coordination on the finger-nose and knee-heel tests. The results of examination of the remaining systems were normal. Laboratory studies disclosed normal values for the following: COMMENT In this patient, the assumption of a causal relationship between the choreoathetoid movements and the bilater¬ al chronic hematomata is based on the lack of any associated metabolic de¬ rangements or structural parenchymal brain disease and the prompt resolution of symptoms after drain¬ age. Bean and Ladisch1 reported chorea in a leukemic child with left-sided sub¬ dural hematoma that resolved com¬ pletely after the latter's evacuation. Their patient had, in addition, papilledema and shift of the midline structures to the right as disclosed by computer¬ ized tomography. Further support of the possibility of a causal relationship between subdural hematoma and chorea is provided by Gilmore and Brenner,2 who noted such a movement disorder as a late complication of right-sided subdural hematoma, with angiographically demonstrated midline shift. It is possible that in both our patient and theirs, extrinsic pres¬ sure on the brain compromised the cerebral circulation, either to cortical areas 6 and 8 or to subcortical struc¬ tures, thereby causing chorea. Langfitt et al' demonstrated that transmis¬ sion of pressure to the brain from an extracerebral mass is more likely to occur if the convexity rather than concavity of the lesion encounters the surface of the brain. As in our patient, loculation may confer a biconvex con¬ figuration to subdural hematoma, thereby rendering it more liable to cause compression of the cerebral par¬ enchyma, to alter cortical and subcor¬ tical functions, and to evoke a move¬ ment disorder. Emily Bliss provided secretarial assistance. References calcium, magnesium, electrolytes, triiodothyronine, thyroxine, erythrocyte serum sedimentation rate, and BUN. Bilateral Accepted for publication June 14, 1980. From the Department of Neurology, St Louis University Medical Center, St Louis. Reprint requests to St Louis University Medi- cal Center, 1221 S Grand Blvd, St Louis, MO 63104 (Dr Kotagal). a Top, Contrast-enhanced computerized scan demonstrating bilateral subdural hematoma with hypo- tomographic (CT) dense, biconvex left frontal loculation. Bottom, CT scan from postevacuation study with evidence of some reexpansion of ventricular system. Downloaded From: http://archneur.jamanetwork.com/ by a University of Iowa User on 05/31/2015 1. Bean SC, Ladisch S: Chorea associated with subdural hematoma in a child with leukemia. J Pediatr 1977;90:255-256. 2. Gilmore PC, Brenner RP: Chorea: A late complication of subdural hematoma. Neurology 1979;29:1044-1045. 3. Langfitt TW, Weinstein JD, Kassell NF, et al: Transmission of increased intracranial pressure: II. Within the supratentorial space. J Neurosurg 1964;21:998-1005.