Post-stroke movement syndromes

POST-STROKE 

MOVEMENT DISORDERS 

Grzegorz Opala 

Department of Neurology Medical Uniwersity of Silesia 

Silesian Stroke Center 

Katowice

KEY POINTS 

• The motor deficit after stroke tends to improve by time, 

• the abnormal movements develop 

• Movement disorders are a rare complication of stroke 

• They can be hyperkinetic or hypokinetic 

• They can occur with damage of different locations in the 

motor pathway, most commonly basal ganglia and 

thalamus 

• Some are self-limiting but treatment may be required for 

symptom control

PERSONAL AND MEDICAL 

SEQUELS OF STROKE 

• Stroke is a leading cause of disability worldwide. 

• It represents a significant cost, not only in terms of 

personal and family disability but also by economic 

cost to state.

Post-stroke movement disorders 

Quality of poststroke life 

• As stroke mortality rates decline, individuals are 

increasingly likely to live with their residual impairments 

and disabilities. 

• The quality of poststroke life is the first of the pivotal topics 

that have to be considered beneath the functional 

outcome.


Motor sequels of stroke 

(pyramidal tract damage) 

• Of patients who survive stroke by more than 30 days: 

– 10% demonstrate complete spontaneus recovery 

– 10% show no benefit from any treatment 

– 80% may benefit, if properly undergo rehabilitation. 

• benefit patients group - 85% should go home after 3 

months of rehabilitation. 

– 85% of them have a chance to be ambulatory 

– 50% independent in performance of ADL



• There are some evidence that in the group of patients 

unable to walk 3 month after the stroke and with 

rehabilitation continued up to 2 years 

- more than 70% were able to walk without assistance.



• Stroke is more disabling than lethal, 

– at least 30% of the survivors make an incomplete recovery 

– a further 20% require assistance in activity of daily living


Motor sequels of stroke. 

Movement disorders 

• Hyperkinetic and hypokinetic movement disorders as 

different types of motor sequels caused by strokes are rare 

• Current knowledge is based on individual case reports, 

small case series and extracts from strokes registries. 

• Some articles review the different types of abnormal 

movements with anatomical correlation, epidemiology, 

treatment and prognosis.


Motor sequels of stroke. 


• Post-stroke movement disorders have been associated 

with both infarcts and cerebral haemorrhage 

• Involuntary abnormal movements may occur as part of : 

– symptomatology of acute stroke, 

– they may be delayed or 

– progressive 

• Transient diskinesias or „limb shaking” spells have been 

described as a symptom of transient ischemic attacks


Post-stroke 

• Many different types of hyperkinetic and hypokinetic 

movement dissorders have been reported after ischaemic 

and haemorrhagic stroke. 

– Dystonia 

– Chorea with or whithout hemiballismus 

– Tremor 

– Parkinsonism 

– Segmental or focal myoclonus 

– Athetosis or pseudoathetosis 

– Asterixis 


Handley a et all Age and Ageing 2009,38,260 - 6



definitions 

• Dystonia 

– a syndrom characterised by prolonged muscle contractions 

causing sustained twisting movements and abnormal postures of 

affected body parts 

• Hemichorea 

– unilateral, rapid involuntary motions of flexion and extension, 

rotation or crossing, which may involve all body parts, but 

predominantly distal parts 

• Hemiballismus (hemiballism) 

– severe, violent, arrhythmic and large amplitude excurtion of a limb 

from proximal joint with an element of rotation



definitions 

• Tremor 

– rapid rythmic oscilation generally of the hands 

• Myoclonus 

– sudden, involuntary jerking of a single muscle or a group of 

muscles



definitions 

• Athetosis 

– slow, sinuous, writhing movements affecting mainly the hands and 

feet 

• Pseudoathetosis 

– abnormal writhing movements, usually of the fingers, caused by 

failure of the joint position sense (proprioception) 

• Asterixis 

– failure to sustain muscle contraction during posture with 

intermittent, generally arrhythmic lapses in muscle tone 

• Parkinsonism 

– triad of bradykinesia, increased tone and tremor



Movement disorders can be: 

– unilateral, 

– bilateral, 

– focal (affecting single part of the body) or 

– segmental (affecting two or more adjacent parts of the 

body)



Frequency and prevelance 

The frequency of post stroke abnormal movements is unclear 

• In a study Alarcon et all. 56 pts developed movement 

disorders, (3,7%) of 1500 stroke pts 

• A review of the hospital based Lausanne Stroke Registry 

identified a prevelence of 1 % and an estimated incidence 

of 0,08% per year. 

– Hemichorea was the most common movement dissorder in the first 

series, while hemichorea – hemiballism was most common in the 

second. 

– Dystonia was the next common movement disorder 

Alarcon F et all J Neurol Neurosurg Psychiatry 2004, 75, 1568 – 74 

Ghica J, Bogousslavsky J in Stroke Syndromes Cambridge University Press 2001,162



Temporal relationship 

• The time scale to develop a movement disorders varies 

considerably from a day of onset to several years after the 

stroke and also depends on the type of movement disorder 

– Chorea presented erlier (4.3 days) and parkinsonism much later 

(117,5 days) 

• There is a wide variability within each movement disorder 

– Dystonia – the delay in developing dystonia after stroke can be 

from 1 day to 5 years



Demography and risk factors 

• Abnormal movements following stroke occur in men and 

women equally 

• Average age 

– 63.3 (range 17 – 90), Alarcon’s study 

– 70 (range 32 - 90), The Lausanne Stroke Registry 

– 57.5 (range 28 –74) study of delayed onset movement disorders 

(35 pts after thalamic infarction), Kim JS, 2001 

• Age of predilection for different movement disorders 

– Chorea affects older people 

– Dystonia younger, Chuang C, 2002



Anathomy, type of stroke and lesion location 

• Different location within the brain have been identified as 

areas that result in abnormal movement when affected by 

stroke 

• The basal ganglia are most often implicated in post stroke 

movement disorders



• The basic function of the pathways of basal ganglia 

circuitry is to act as a cortical feedback loop in which 

signals from the neocortex are relayed through the 

striatum, pallidum and thalamus back to the cortex. 

• Interruption of direct or indirect pathways by focal lesion 

may lead to movement disorders 

• There are no specific sites of arterial territories for any 

given diskinesias 

• Lesions in different parts of the motor pathways may be 

responsible for the same movement disorders




• Small vessel disease, with small deep infarcts, was the 

most common subtype of stroke leading to abnormal 

movements. 

• Patients with deep lesions in the basal ganglia, thalamus 

and brain stem, who developed abnormal movements, had 

significantly more haemorrhages compared to controls. 

Alarcon F et all J Neurol Neurosurg Psychiatry 2004, 75, 1568 - 74




• Large and medium vesels atherothrombosis and cardiac 

embolism are other causes of strokes leading to abnormal 

movements 

• In group of pts with delayed onset dyskinesias after 

thalamic stroke was found that 62.9% of pts had 

haemorrhagic strokes, Kim JS Brain 2001 

• In cohort study with hemiballism all the pts had infarcts. 

Ristic A et all, Stroke 2002




Conclusions 

• Lenticular lesions are the common lesions that result in 

dystonia and chorea +/- hemiballism, 

• Lesions in the posterior thalamus or lesions disrupting the 

dentatorubrothalamic pathway are the most common 

cause of tremor 

• Post–stroke lesions in the basal ganglia (mainly striatum or 

lentiform nucleus) which can be unilateral or bilateral are 

the most common cause of parkinsonism


Abnormal movements and other associated 

stroke features 

• While post-stroke dyskinesias are offen reported as pure 

movement disorders, they can be: 

– variable 

– encompass several components and 

– difficult to classify 

• Chorea and hemiballismus can be part of the same 

spectrum of disease 

– The term hemichorea-hemibalism is used to reflect this. 

– Athetosis and sometimes dystonia may also be combined this 

hemichorea




• Dystonia can involve the ipsilateral face, arm and leg 

(hemidystonia) or can be segmental or focal 

– Focal dystonia can affect the hand (most commonly), foot, facial or 

othere muscles 

– Dystonia can be associated with abnormal movements such as 

jerks (dystonic myoclonus),tremor like (dystonic tremor) or athetoid 

movements. 

– The abnormal twisting movements of dystonia are cased by cocontraction 

of agonist and antagonist muscles and voluntary 

movements worsens this. 

– In contrast to post-stroke spasticity, which is associated with 

muscle weakness and increased inhibitory impulses, dystonia is 

associated with muscle overactivity caused by reduced inhibition at 

many levels of the motor system




• Tremor has been observed to occur most commonly in a 

multifocal or segmental dystribution. Most studies have 

found that the tremors generally occur on action; however, 

some exhibit a mixture of rest, postural or kinetic 

coponents. 

– The term „rubral” or midbrain tremor has been used to describe a 

resting tremor that becomes more severe on maintaining a posture 

and most severe at intention. 

– The involvement of the red rubber nucleus has not always been 

identyfied.





• Parkinsonism developing after a stroke is predominantly 

bilateral and is charakterised by lower body signs, no 

tremor and a history of risk factors including hypertention. 

Some patients develop hemiparkinsonism. 

• Asterixis is usually unilateral, associated with mild initial 

weakness and affects the upper limb predominantly. 

Bilateral asterixis has also been described




• Athetosis is uncommon and is often a component of a 

mixed involuntary movement disorders such as dystoniaathetosis 

or choreo-athetosis. 

Proprioceptive loss impairs stability of movement at joints 

and leads to pseudoathetosis




• Myoclonus is a rare symptom in patients with stroke, and 

generalised myoclonus has not been reported. 

• Segmantal myoclonus has been reported in posterior 

circulation strokes particulary: 

– midbrain 

– pontine 

– thalamic 

Palatal myoclonus has been described in pontine or bulbar strokes



Abnormal movements and other associated stroke features 

• Transient dyskinesias described as repetitive, involuntary 

„shaky limb” episodes have been reported in carotid 

territory TIAs in association with severe unilateral or 

bilateral carotid stenosis or with ischaemia of the vertobasilar 

system 

• They last a few seconds or minutes and can be 

precipitated by sitting or standing 

– They have been described as shaking, flapping or trembling and 

my be difficult to distinguish from epileptic seisures, although eeg 

during attacks do not show any epileptiform activity. 

– Diminished cerebral blood flow has been documented and 

symptoms may disappear after endarterectomy 

Ghica J, Bogousslavsky J Stroke Syndroms 2001 

Ghica j et all J Neurol Science 1997,146,109 

Tatemichi TK et all Stroke 1990,21,341



Treatment 

• Few large-scale studies have been possible due to small 

numbers and there are therefore no firm guidelines for the 

management of these conditions 

• Hemiballismus, hemichorea, athetosis – pharmacological 

therapy comprises anti-dopaminergic therapy with typical 

and atypical neuroleptics and catecholamine-depleting 

agents. 

• Dystonia - treatment options may be used alone or in 

combination 

– Botuline toxin injections have been a major breakthrough in the 

management 

– Other treatments include benzodiazepines, baclofen, 

anticholinergic drugs and dopamine-depleting/blocking agents



Treatment 

• Tremor is particularly refractory to drug treatment 

– Rubral and palatal tremor may respond to clonazepam and sodium 

valproate 

– Propranolol may help dampen tremor from all cases 

• Myoclonus – the most commonly used drugs are the 

GABAergic drugs, clonazepam and sodium valproate 

– Clonazepam is effective in all types of myoclonus 

– Sodium valproate is effective in cortical and subcortical myoclonus



Treatment 

• Parkinsonism – true vascular parkinsonism rarely respond 

to convetional dopaminergic therapy 

– Treatment for risk factors for atherosclerotic diseases – antiplatelet 

agents, statins and anti-hypertensives. 

• Idiopatic Parkinson’s disease and vascular parkinsonism 

can co-exist so we can give levodopa in order not to miss 

any dopaminergic responsiveness. 

– Just as important in the apparent non-responders is to wean off 

levodopa to confirm that no response, in fact, occurred and to stop 

unneccessary medication


Treatment of post-stroke movement disorders 

Motor cortex stimulation (MCS) 

Deep brain stimulation (DBS 

• DBS of the thalamic nuclei has been useful in more than 

70% patients with post-stroke involuntary movements 

(hemibalism, chorea, athetosis and tremor) 

• In clinical trials on MCS for the control post-stroke pain, it 

was discovered that co-existent involuntary movements 

could be controlled. 

• Reversible treatment option for severe, refractory disorders 

– invasive 

– expensive

KEY POINTS. 

TAKE HOME MESSAGES 

• The motor deficit after stroke tends to have improved by 

the time the abnormal movement develops 

• Movement disorders are a rare complication of stroke 

• They can be hyperkinetic or hypokinetic 

• They can occur with damage to many different locations 

in the motor pathway, most commonly basal ganglia and 

thalamus 

• Some are self-limiting but treatment may be required for 

symptom control



Conclusions 

• Many different varieties of abnormal movements can be 

found after a stroke either acutely or as a delayed sequel 

• They can be hyperkinetic (hemichorea - hemibalismus) or 

hypokinetic (vascular parkinsonismus) 

• Main cause are lesions in basal ganglia or thalamus but 

can occur also with stroke at many different locations in the 

motor circuit. 

• Many are self – limiting but treatment may be required for 

symptom control

Post-stroke movement syndromes

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