Acute ischaemic stroke-related choreoathetosis treated with arterial thrombectomy

Abstract

A rare case of acute choreoathetosis after acute stroke is presented. This 66-years-old, right-handed Caucasian woman presented with weakness of her right arm and right leg with dysarthria, which resolved by the time she arrived in the emergency department. No obvious focal sign apart from the abnormal choreoathetoid movement of the right arm and leg and of the neck was present. Her medical history included atrial fibrillation without anticoagulation. CT head was nil acute (Alberta Stroke Program Early CT Score of 10). CT angiography of the carotids showed a hyperdense M2 segment of the left middle cerebral artery. Intravenous thrombolysis immediately followed by thrombectomy was decided. Using the Penumbra aspiration device (ACE 68) two clots were removed with two aspirations. A small distal clot remained but partial recanalisation (Thrombolysis in Myocardial Infarction/Thrombolysis in Cerebral Infarction 2b) was achieved. 30 seconds after restoring blood flow, the choreoathetoid movements ceased. The patient was brought to intensive care for further monitoring, which was uneventful.

Keywords: movement disorders (other than Parkinsons); neuroimaging; stroke.

Figure 1

System generated Brainomix eASPECTS scoring did not flag any hypodensities above threshold. The ASPECTS is a 10-point quantitative topographic head CT scan score used to quantify early ischaemic change of acute stroke in patients with middle cerebral artery stroke. Segmental assessment of the middle cerebral artery vascular territory is made and one point is deducted from the initial score of 10 for every predefined region acutely involved. An ASPECTS ≤7 indicates a more severe stroke with worse functional outcome. ASPECTS, Alberta Stroke Programme Early CT Score.

Figure 2

Static image of 4D reconstruction of CT angiogram showing occlusion of the left M2 branch (red arrow) and surrounding collaterals. Please note the section is above downwards (ie, left and right sides are transposed) for better visualisation of circle of Willis and its branches.

Figure 3

Image acquired from digital subtraction angiography: area (inside the red circle) demonstrating occlusion of the left M2 branch (notice the abrupt cut-off of flow).

Figure 4

Image acquired from digital subtraction angiography: area (inside the red circle) demonstrating partial recanalisation (TIMI/TICI 2b) of the occluded left M2 branch, which was presumably responsible for supplying the part of the basal ganglia responsible for the choreoathetoid presentation. TIMI/TICI, Thrombolysis in Myocardial Infarction/Thrombolysis in Cerebral Infarction.

Figure 5

Small area of infarct (inside red circle) in the left parietal white matter saving a surrounding much larger area from infarct, some haemorrhagic imbibition was also seen. Without timely intervention, the area of infarct would presumably be much bigger with persistent disability.