Dados do Trabalho

Título

an unusual presentation of an acute ischemic stroke due to large vessel oclusion

RESUMO

Case-Report:
A 58-year-old male with unremarkable medical history, was addmited in the emergency department presenting sudden abnormal movements in right side limbs. At initial neurologic evaluation, the patient showed only hemichorea on the right side, and his National Institute of Health Stroke Scale (NIHSS) score was zero. After excluding cerebral hemorrhages in brain CT scan and no contraindications for chemical thrombolysis, Alteplase was administered. Cranial and cervical CT angiography showed tandem occlusion in the left internal carotid artery and middle cerebral artery. Brain MRI displayed, an area of restricted diffusion in the left insula. He was admitted at Stroke Unit for etiologic evaluation, in addition to acute phase care. There was a fluctuation of deficits in the first 24 hours, nonetheless the patient was discharged after 4 days of hospitalization with complete improvement of abnormal movements. The mechanism was defined as athero-embolic with internal carotid artery occlusion, probably chronic due to flow distribution pattern evidenced in carotid, vertebral and transcranial doppler scan.

Discussion:
Although hemichorea is an uncommon symptom of AVC, studies reveal that vascular etiology is the most prevalent non-genetic cause among the various diseases that induce chorea. The results of a study published in Neurology showed lesion network mapping to anatomically heterogeneous lesions that can cause hemichorea-hemiballismus, and while the findings failed to localize a single region, it did show a 92 percent connectivity to the posterolateral putamen, which plays a central anatomical and functional role within the basal ganglia-thalamocortical motor loop, emphasizing its importance in this unknown pathophysiology. Research indicates that most patients experience complete remission of hemichorea-hemiballism within a few days after stroke vascularization. The underlying cause of the clinical finding must be treated, as in the case of the highlighted patient, which even without thrombectomy, presented full remission post thrombolysis

Final Comments:
A sudden onset hemichorea should be treated as an acute stroke until proven differently. This case supports the idea that the cortico subcortical transition of the insular region has a role in the genesis of aberrant hyperkinetic movements, as well as a probable functional linkage with the basal ganglia

Palavras Chave

Chorea; Stroke; Movement Disorder; Carotid Stenosis; Insula