What are the symptoms and management of a right basal ganglia infarction?

Right Basal Ganglia Infarction Symptoms and Management

Right basal ganglia infarctions typically present with left-sided hemiplegia or hemiparesis, accompanied by possible cognitive and behavioral disturbances, and may include movement disorders such as dystonia or chorea. These symptoms result from damage to critical structures within the basal ganglia circuit that control movement and cognitive functions.

Clinical Presentation

Motor Symptoms

• Left-sided hemiplegia or hemiparesis (most common presentation, seen in 30 of 36 patients in one study) 1
• Micrographia (small handwriting) that may be context-dependent 2
• Movement disorders:
  • Dystonia (common)
  • Chorea (common)
  • Tremor (less common)
  • Rarely: tic, restless leg syndrome, or blepharospasm 3

Cognitive and Behavioral Symptoms

• Decreased sustained attention
• Impaired verbal fluency (word generation)
• Difficulty with idea generation
• Significant impairment in abstraction abilities (verbal and visual) 2
• Rapid onset cognitive and behavioral changes (especially with bilateral involvement) 4

Other Neurological Symptoms

• Hemisensory changes (in approximately 14% of cases) 1
• Aphasia (in approximately 14% of cases) 1
• Seizures (in approximately 14% of cases) 1
• Altered consciousness (especially with bilateral lesions) 1

Diagnostic Approach

Neuroimaging

• MRI is more sensitive than CT for detecting basal ganglia lesions 5

  • T2-weighted MRI typically shows hyperintensity in the region of the basal ganglia
  • Diffusion-weighted images (DWI) show restricted diffusion in acute infarcts
  • Fluid-attenuated inversion recovery (FLAIR) images show early abnormalities

• CT findings:

  • Early signs include slight effacement of the right lentiform nucleus
  • Later development of frank hypodensity in the affected territory
  • Possible hemorrhagic transformation in the basal ganglia 5

Additional Testing

• Transcranial Doppler sonography can be useful for monitoring elevated intracranial pressure and detecting cerebral herniation 5
• Consider testing for underlying causes:
  • Vascular imaging (CTA, MRA, or conventional angiography) to identify large vessel occlusion
  • In children, consider post-varicella arteriopathy 6
  • In young adults with unexplained stroke, consider metabolic disorders (MELAS, Fabry's disease) 5

Management

Acute Management

1. Admission to a unit with neuromonitoring capabilities is essential for patients with large territorial strokes at risk for swelling 5
2. Early neurosurgical consultation should be obtained for patients who may require decompressive surgery if deterioration occurs 5
3. Monitor for and manage cerebral edema and increased intracranial pressure
4. Assess for and manage hemorrhagic transformation, which is common in large infarcts 5

Specific Treatments

• For acute ischemic stroke, standard stroke protocols apply (thrombolysis if eligible, antiplatelet therapy)
• For specific underlying causes:
  • MELAS: Consider L-arginine, coenzyme Q10, or L-carnitine (though evidence is limited) 5
  • Fabry's disease: Enzyme replacement therapy with galactosidase A 5

Rehabilitation

• Physical therapy for motor deficits
• Occupational therapy for activities of daily living
• Speech therapy if language deficits are present
• Cognitive rehabilitation for executive function deficits

Prognosis

• Most children with a single unilateral infarction have a good prognosis 1
• Adults with isolated basal ganglia infarcts often have preserved general intelligence, simple attention, concept formation, and explicit memory 2
• Specific cognitive deficits may persist, particularly in non-routine response selection and performance 2
• Bilateral lesions generally have worse outcomes than unilateral lesions 1, 4

Common Pitfalls and Caveats

1. Right basal ganglia infarcts may be misdiagnosed as purely motor disorders without recognition of the cognitive/behavioral components
2. Micrographia may be context-dependent and not apparent in all writing tasks 2
3. In children, basal ganglia infarcts can present with altered mental status and may be mistaken for encephalitis or metabolic disorders 5, 1
4. Hemorrhagic transformation is common in large infarcts and may complicate management 5
5. Bilateral basal ganglia lesions may present primarily with cognitive and behavioral changes rather than motor symptoms 4

Understanding the complex interplay between motor and cognitive symptoms in right basal ganglia infarctions is essential for proper diagnosis and management of these patients.