Objective: Case report.

Background: Symptomatic focal dystonia is most commonly secondary to lesions involving the basal ganglia. Previous reports have documented the occurrence of focal dystonic postures and chorea with lesions of the proprioceptive sensory pathways (pseudodystonia), including focal parietal cortical damage. There are no approved treatments for the disabling dystonic postures that often result from these lesions. The effectiveness of botulinum toxin on idiopathic limb dystonias, on the other hand, has been well established. We report a case of a patient with a parietal hand pseudodystonia treated with botulinum toxin.

Methods: A 74 year-old woman with a history of right opercular stroke (with a parietal, frontal and insular infarct on CT scan) presented initially with a left sensorimotor deficit. Despite improvement of limb paresis with physiotherapy, the patient complained of abnormal postures and a non-functional left hand which hindered her activities of daily living (ADLs). On neurological examination, there was mild right hand somatosensory and proprioceptive impairment, slight astereognosis, minor left upper limb (UL) paresis (4+/5 MRC) as well as slight spasticity and moderate pseudodystonia of the UL. US-guided botulinum toxin injections were proposed to ameliorate the pseudodystonia. Botox® (Allergan) was administered to forearm muscles on 4 sessions at 3-month intervals. Doses and pattern of injected muscles were adjusted as needed in subsequent treatments (including both agonist and antagonist muscles). Total dose on last treatment was 90U.

Results: The patient was assessed at baseline (P0-pre-treatment) and 6 weeks after the 4rd treatment (P3) using the Goal attainment scaling (GAS). She reported significant improvements in performing ADLs such as dressing, cooking and grasping, gaining autonomy in performing these tasks. A reduction in involuntary movement frequency and severity from P0 to P3 was seen, along with reduced interference of pseudodystonia in other activities. GAS change score (P0 to P3) was 25,4.

Conclusions: We report a non-functional pseudodystonic hand, which improved after treatment with ultrasound guided toxin botulinum treatment. The present case illustrates the potential usefulness of botulinum toxin in the treatment of incapacitating dystonic postures secondary to central somatosensory deficits originating outside the basal ganglia.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/parietal-hand-pseudodystonia-significant-functional-gains-with-ultrasound-guided-botulinum-toxin-treatments/