Objective: Describe phenomenology of rare movement disorders in stroke presentation and it pathophysiology

Background: Acute movement disorders are a rare presentation of ischaemic stroke. hemichorea is the most frequent type of acute movement disorder caused by stroke. Acute neuropsychiatric manifestations such as depression or anxiety are common. Psychotic behaviors are rarely seen. 

Methods: We present an unusual case of acute hemichorea with content-specific delusion caused by a right caudate nucleus ischaemic stroke

Results: A  65 year-old man without significant medical history  presented a persistant left hemichorea of acute onset with athetosis and synkinesis. There was no pyramidal, extrapyramidal or cerebellar sign. The patient was agitated and logorrheic, expressed extreme anxiety over a secret plot against him by the medical team, whom he believed retained information concerning his imminent death, believing they were attempts to kill him. He called the police at night to inform that he might die soon. The patient had trouble recalling our team’s daily visits. Psychiatric examination concluded to persecution-themed delusion. Brain MRI showed 2 hyperintense lacunar ischemic lesions on Diffusion-weighted imaging (DWI) in the right caudate nucleus. A lumbar puncture was performed, showing normal cerebrospinal fluid findings. EEG, CT angiogram  and rythmology were normal. He was treated with acetylsalicylic acid and discharged from the Neurology to Psychiatry, where treatment by cyamemazine was initiated.

Follow-up at two weeks found a remitting delusion.

Conclusions: Hemichorea must be recognised  as a stroke symptom. The contralateral striatum is the most frequently involved region, leading to an interruption of the inhibitory transmission from the striatum to the external globus pallidus. .

Content-specific delusions occur in a number of neurological disorders with a particular correlation between delusion formation and discrete brain lesions in the right hemisphere. There has been few reports on psychosis caused by basal ganglia lesions.

Our patient draws interest from his misleading «Huntington Disease-like» presentation of stroke symptoms, mimicking this neurodegenerative disorder’s features. The precise radioclinical correlations established from this case supports theories on the relationships between delusional toughts and right nucleus caudate lesions mediated via dysfunction of the inferior prefrontal cortex.

References: McMurtray, Aaron M., David L. Sultzer, Lorena Monserratt, Tuty Yeo, and Mario F. Mendez.. “Content-Specific Delusions from Right Caudate Lacunar Stroke: Association with Prefrontal

Hypometabolism.” The Journal of Neuropsychiatry and Clinical Neurosciences 20, no. 1 (2008):62–67. doi:10.1176/jnp.2008.20.1.62.

Béjot, Yannick, Maurice Giroud, Thibault Moreau, and Isabelle Benatru. “Clinical Spectrum of

Movement Disorders after Stroke in Childhood and Adulthood.” European Neurology 68, no. 1 (2012): 59–64. doi:10.1159/000336740.

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