Hemiballismus secondary to metastatic breast cancer

Abstract

Dear Editor,Hemiballismus, a term derived from a Greek wordmeaning ‘‘to throw’’, is characterized by involuntary,flinging, throwing and kicking large-amplitude movementsof the limbs of one side of the body. The area of the brainusually implicated in its pathophysiology is the contralat-eral subthalamic nucleus. However, hemiballismus has alsobeen reported to occur outside the subthalamic nucleus atpoints that involve afferent or efferent pathwaysconnecting the nucleus to its projection areas including thebasal ganglia, and motor and premotor cortex. It is believedthat hemiballismus is the overt clinical manifestation ofdisinhibited thalamic outflow when tonic subthalamicactivity is interrupted [1].The most common cause of hemiballismus is cerebro-vascular disease, but a range of diseases can occur(hemorrhage, vascular malformations, tuberculomas,demyelinating plaques, tuberous sclerosis, toxoplasmosis,non-ketotic hyperglycemia, lupus vasculitis, leukemicinfiltration of the brain, primary brain tumors and drug-induced disease) [2]. Herein, we report a patient withmetastatic breast cancer who presented with hemiballismus.A 73-year-old illiterate woman with a past medicalhistory of asthma and cardiac insufficiency was diagnosedwith bone and pulmonary metastatic breast cancer andunderwent mastectomy and chemotherapy in June 2012.She presented to a neurological consultation in February2013 with a 5-year history of progressive cognitiveimpairment that subsequently led to dementia withdependence for most activities of daily living and a1-month history of generalized involuntary flingingmovements of her proximal limbs and face. Examinationshowed a third nerve palsy (sequela from traumatic injury)combined with a lower-limb predominant right hemichorea(Video1). Brain magnetic resonance imaging revealedmultiple contrast-enhanced nodular lesions, one of them inthe left subthalamus (Fig. 1). Cerebrospinal fluid analysiswas normal. She received risperidone with partial recoveryof chorea and cranial radiotherapy.Hemiballismus secondary to metastatic tumors are dis-tinctly rare, but it has already been reported with carcino-mas of the breast, lung and gall bladder [3, 4]. The firstcase of a metastatic lesion affecting the subthalamus wasreported in 1973 [3] and it was followed by a French case