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Hemiballlsm is a rare movement disorder which is due to lesion or malfunction of the subthalamic nucleus (STN) and its connections, according to various neurophysiological data. Various causes of this condition have been described, usually related to basal ganglia dysfunction. There are only three references in the literature of traumatic hemiballism. We report a case of post-traumatic hemiballism, due to a contusion of the Subthalamic regional area, and review the relevant literature.
KEY WORDS: Hemiballism * Traumatic brain injury * Basal ganglia * Subthalamic nucleus.
Hemiballism is a rare movement disorder characterized by involuntary, violent, coarse, irregular and arrhythmic nonadaptive and poorly patterned movements of the extremities of one half of the body, which stop during sleep.The disorder is related to injury of the contralateral Subthalamic Nucleus (STN), although cases of hemiballism accompanied with ipsilateral STN lesion have been described in the literature. Multiple clinical entities have been reported as possible causes, such as hemorrhage,1 infarcts,2 Syndeham's chorea,3 metastatic tumors,4 AVMs,5 tuberculoma of the basal ganglia,6 encephalitis,3 SLE7, AIDS,8 basal ganglia calcifications,3 non-ketotic hyperglycemia,9 multiple sclerosis,10 hypertensive crisis,3 hypoparathyroidism n and postsurgical injuries.12 There are also case reports of hemiballism due to ependymal cysts,13 parietal lobe- tumors 14 and infarcts.15
Three cases of posttraumatic hemiballism have been reported. No radiological findings were present in two of these cases,16-18 while a lesion in the region of STN was found on SPECT in the third case.19
We present a case where three of the aforementioned causative factors were present, while the possible participation of each of them is discussed.
The neurophysiological hypothesis suggests that a STN lesion results in reduced inhibitory impulses from the ventral part of the globus pallidus and the reticular substantia nigra, leading to reduced activity of the GABA-ergic inhibitory subthalamic-pallidal pathway. This, in turn, causes increased glutaminergic excitatory cortical activity. Stereotactic0 -lesional17, 18, 20 and radiosurgical 5 treatment techniques have been developed, on this basis.
Case report
A 28-year-old male was admitted to our emergency department because of a head injury due to a fall from a 2 meters height. On initial physical examination the patient was haemodynamically stable. His BP was 135/90 mmHg and the pulse rate was 80 pulses/min. His CBC revealed hematocrit: 42%, hemoglobin: 15 mg/dL, white blood cells...