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CASE REPORT
Choreoathetosis after subarachnoid hemorrhage related to an aneurysm of the posterior fossa
Júlio Leonardo Barbosa PereiraI, Lucas Alverne Freitas de AlbuquerqueI,
Corresponding author
lucasalverne@yahoo.com.br

Tel.: 31 3238-8100
, Mauro Cruz Machado BorgoI, Gerival Vieira JuniorI, Paulo Pereira ChristoII, Gervásio Teles C. de CarvalhoIII
I Neurosurgery, Santa Casa de Belo Horizonte, Belo Horizonte/MG, Brazil.
II Research Program of the Santa Casa, Belo Horizonte/MG, Brazil.
III Neurosurgery, Santa Casa de Belo Horizonte and Faculdade de Ciências Medicas de Minais Gerais, Belo Horizonte/MG, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Non-traumatic subarachnoid hemorrhage &#40;NSAH&#41; is a neurological emergency with a high rate of death and complications&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> A ruptured intracranial aneurysm accounts for approximately 80&#37; of NSAH cases&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">The classic clinical manifestations of NSAH are headache&#44; nausea and vomiting&#44; focal neurological signs&#44; meningeal irritation&#44; and a reduction in the level of consciousness&#46; In the present work&#44; we describe a case of choreoathetosis that developed in a young patient who presented with a subarachnoid hemorrhage &#40;SAH&#41; related to an aneurysm of the posterior fossa&#46; We also review the corresponding literature&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para30" class="elsevierStylePara elsevierViewall">A 17-year-old boy&#44; with no previous co-morbidity or neurological disability&#44; reported the sudden onset of a severe headache associated with an alteration of his level of consciousness and meningeal signs&#46; Upon admission to our department&#44; three days after the acute event&#44; he was confused&#44; dysarthric&#44; exhibited choreoatetoid movements of the distal upper limbs&#44; exhibited postural instability&#44; and exhibited the inability to walk&#44; stand up&#44; or sit up without help&#46; The choreoathetosis began just after the onset of the SAH&#46; The results of the motor&#44; sensitivity &#44; and reflex examinations were normal&#46; The patient&#39;s hyperkinesia ceased with sleep&#46; In addition&#44; there was no family history of movement disorders&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">A computed tomography &#40;CT&#41; scan revealed a hemorrhage in the fourth ventricle but no evidence of a parenchyma lesion&#46; A cerebral angiography &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41; revealed a small saccular aneurysm of the basilar artery&#44; which was located close to the emergence of the anterior inferior cerebellar artery &#40;AICA&#41;&#46; No evidence of vasospasm was observed&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">On the fourth day after the ictus&#44; the patient was administered haloperidol&#44; and a progressive reduction in the frequency of choreoatetoid movements was observed&#46; However&#44; the dysarthria and postural instability remained&#46; The patient was administered phenytoin for seven days prior to the endovascular aneurysm repair&#44; which was completed uneventfully&#46; A control CT scan did not reveal hydrocephalus&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">At the one-year follow-up visit&#44; the patient did not exhibit any choreoatetoid movements&#59; however&#44; the cerebellar alterations remained&#44; with an important static and dynamic imbalance and significant dysmetria&#46; Magnetic Resonance Imaging &#40;MRI&#41; at the one year follow-up revealed cerebellar atrophy &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1B</a>&#41;&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para70" class="elsevierStylePara elsevierViewall">Stroke-related movement disorders are uncommon &#40;3&#46;6&#37;&#41; and are very rare in SAH cases &#46; Chorea&#44; tremor&#44; dystonia&#44; Parkinsonism&#44; and myoclonus have all been associated with cerebral infarcts and hemorrhaging&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Movement disorders&#44; which represent a portion of the clinical spectrum of acute stroke&#44; may be delayed or progressive&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">The first case of a movement disorder &#40;chorea&#41; after a SAH was reported by Sakai et al&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> and occurred eight days after the SAH onset&#46; The CT scans revealed a SAH with ventricular dilation and periventricular lucency involving the bilateral caudate nuclei&#46; The chorea was attributed to the vasospasm and hydrocephalus&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a></p><p id="para90" class="elsevierStylePara elsevierViewall">In another case&#44; reported by Morigaki et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib5">5</a> the involuntary movements began shortly after the SAH onset&#46; There was no acute hydrocephalus&#44; and the authors attributed the symptoms to a hematoma on the corpus callosum that resulted from a rupture of an aneurysm of the distal accessory anterior cerebral artery&#46; The hyperkinetic involuntary movements were suggested to have occurred due to the interruption of the cortico-striato-pallido-thalamo-cortical feedback loop&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Alarc&#243;n et al&#46; analyzed 1&#44;500 consecutive stroke patients over a period of ten years to identify patients with a movement disorder&#44; which was observed in only 56 patients &#40;3&#46;6&#37;&#41;&#46; Chorea was the most common movement disorder &#40;35&#46;7&#37;&#41;&#46; Thirty-nine &#40;69&#46;6&#37;&#41; patients experienced an ischemic stroke&#44; 14 &#40;25&#37;&#41; experienced a parenchymal hemorrhage&#44; and only three &#40;5&#46;3&#37;&#41; experienced a SAH&#46; All of the patients with a movement disorder that was secondary to a SAH in the Alarc&#243;n et al&#46; series presented with a tremor &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41; as their principal involuntary movement&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a></p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">The time that elapses between a stroke onset and the development of a movement disorder is variable&#46; Alarc&#243;n et al&#46; observed involuntary movements that began on the first day of the stroke in 12&#46;5&#37; of their patients but reported cases in which the abnormal movement occurred much later&#44; including Parkinsonism that began ten months after the stroke&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a></p><p id="para120" class="elsevierStylePara elsevierViewall">While analyzing the literature data on movement disorders after a SAH &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#44; we observed a total of six patients &#40;including this reported case&#41;&#46; Of these six patients&#44; five were female and one was male&#44; with a mean age of 58&#46;6 years &#40;SD 21&#46;6&#44; ranging from 17 to 74 years&#41;&#46; Chorea or choreoathetosis was observed in three of these cases&#59; tremor was observed in the other three cases&#46; One patient in the tremor group exhibited associated dystonia&#46; Our case is very atypical because he is the youngest patient ever described and was the only male to present with SAH-related involuntary movement&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">In our case&#44; no vasospasm&#44; hydrocephalus&#44; or even direct injury to the basal ganglia was observed that could explain the choreoathetosis&#46; We suggest that the hematoma that was located in the fourth ventricle may have disturbed the dentato-rubro-thalamo-cortical pathways&#44; leading to transient choreoatetoid movements&#46; Another hypothesis&#44; without evidence of a vasospasm&#44; is that the movement disorder was secondary to an ischemic lesion in the thalamogeniculate artery &#40;a branch of the posterior cerebral artery&#41;&#44; which disturbed the posterior ventral thalamic areas related to the basal ganglia circuit&#46;</p></span></span>"
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Hypothesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Sakai et al&#46; &#40;1991&#41;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Chorea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">8 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">ICA - AchoA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Vasospasm Hydrocephalus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Alarc&#243;n et al&#46; &#40;2004&#41;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn2">&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Intraventricular hemorrhage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Alarc&#243;n et al&#46; &#40;2004&#41;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn2">&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Hydrocephalus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Alarc&#243;n et al&#46; &#40;2004&#41;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Tremor&#44; dystonia&#44; ataxia and dysmetria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn2">&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top"><a class="elsevierStyleCrossRef" href="#tfn3">&#8727;&#8727;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Hydrocephalus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Morigaki et al&#46; &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Choreoathetosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Ictus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Distal accessory ACA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Corpus callosum hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top" style="border-bottom: 2px solid black">Pereira et al&#46; &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Choreoathetosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Ictus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Basilar artery at AICA emergence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Disturbance of the dentato-rubro-thalamo-cortical pathways&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                      "titulo" => "Cerebral aneurysms"
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                            0 => """
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                            1 => """
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                              F Alarc&#243;n \n
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                              JCM Zijlmans \n
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                        "volumen" => "43"
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                        "paginaFinal" => "880"
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Article information
ISSN: 18075932
Original language: English
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2024 August 36 15 51
2024 July 23 19 42
2024 June 15 12 27
2024 May 15 15 30
2024 April 12 16 28
2024 March 14 13 27
2024 February 9 12 21
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2023 December 6 15 21
2023 November 10 20 30
2023 October 14 24 38
2023 September 14 23 37
2023 August 8 7 15
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2023 June 21 5 26
2023 May 40 0 40
2023 April 44 0 44
2023 March 52 2 54
2023 February 5 1 6
2023 January 6 1 7
2022 December 11 2 13
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos