Isolated Hemichorea-Hemiballismus as the Presenting Manifestation of Thalamic Intracerebral Hemorrhage: A Long-Term Treatment Course With Tetrabenazine and Aripiprazole.

Post-stroke movement disorders are uncommon, and hemichorea-hemiballismus is most often associated with lesions involving the basal ganglia or subthalamic region. Thalamic lesions are a recognized but less frequent cause. We report a 78-year-old right-handed woman who developed sudden involuntary jumping and dancing movements of the right foot, which later spread to the right arm. She had no weakness, sensory loss, dysarthria, visual symptoms, headache, or loss of consciousness. Examination showed continuous right-sided hemichorea-hemiballismus with preserved strength and sensation. Non-contrast computed tomography demonstrated a focal acute left thalamic intracerebral haemorrhage, with no additional haemorrhage, mass effect, midline shift, or acute infarction identified on the initial scan. Four-factor prothrombin complex concentrate was administered for reversal of edoxaban-associated anticoagulation, and anticoagulation was initially withheld. Tetrabenazine was started and gradually increased to a maximum of 25 mg three times daily, with substantial improvement in the involuntary movements and participation in rehabilitation. Attempts to reduce the dose were followed by worsening of the movements. At higher doses, however, she developed significant irritability, low mood, and emotional lability. Tetrabenazine was therefore gradually withdrawn, and aripiprazole was started at 2.5 mg daily and increased to 7.5 mg daily. At subsequent follow-up, the hemichorea remained markedly improved, and her mood improved after tetrabenazine was discontinued. Mild choreiform movements persisted beyond 12 months, and aripiprazole was later increased to 10 mg daily. This case shows that a focal thalamic haemorrhage can present with isolated hemichorea-hemiballismus and that symptoms may remain clinically relevant for more than a year. It also highlights the need to balance symptomatic benefit against neuropsychiatric adverse effects when using tetrabenazine and to consider alternative treatment when symptoms persist.