Management of Leg Pain Followed by Hemiballismus in Older Adults
Urgent neuroimaging with MRI or CT is mandatory to identify the underlying cause—most commonly stroke or nonketotic hyperglycemia—followed by immediate initiation of dopamine receptor blocking agents, with haloperidol as first-line therapy starting at low doses (0.5-2 mg orally 2-3 times daily) titrated to effect. 1, 2
Immediate Diagnostic Workup
The acute onset of leg pain followed by hemiballismus demands urgent evaluation for vascular or metabolic etiologies:
- Obtain stat blood glucose and hemoglobin A1c to rule out nonketotic hyperglycemia, which has become an increasingly common cause of hemiballismus in recent years 1, 3
- Perform urgent brain MRI (or CT if MRI unavailable) to identify stroke, hemorrhage, or other structural lesions in the contralateral basal ganglia, particularly the subthalamic nucleus, though lesions outside this nucleus are actually more common in clinical series 1, 3
- Consider HIV testing in appropriate clinical contexts, as HIV-related complications have emerged as a notable cause 1
Pharmacological Management
First-Line Treatment
Dopamine D2 receptor blockers are the cornerstone of symptomatic treatment:
Haloperidol is the most extensively studied agent, with evidence showing it can greatly reduce or eliminate movements in acute vascular hemiballismus 2
- Start at 0.5-2 mg orally 2-3 times daily
- Titrate upward based on response and tolerability
- In successful cases, withdrawal is often possible within 6 months without recurrence 2
Olanzapine represents a valuable alternative, particularly when haloperidol fails or causes intolerable side effects 4
Alternative Pharmacological Options
- Tetrabenazine is an effective alternative that depletes presynaptic dopamine stores 1, 3
- Monitor closely for extrapyramidal side effects and adjust dosing in elderly patients who may be more sensitive to these medications 1
Address the Underlying Cause
Treatment must be directed at the etiology:
- For hyperglycemic hemiballismus: Aggressive glucose control often leads to spontaneous resolution without need for long-term neuroleptic therapy 1, 3
- For ischemic stroke: Standard stroke management protocols including antiplatelet therapy, risk factor modification, and rehabilitation 1
- For hemorrhagic stroke: Blood pressure control and neurosurgical consultation if indicated 1
Prognosis and Treatment Duration
Contrary to older literature describing grave prognosis, modern series show hemiballismus generally has favorable outcomes:
- Many patients experience spontaneous improvement or complete remission, particularly when the underlying cause is treated 1, 2, 3
- In vascular cases treated with neuroleptics, drug withdrawal is often successful within 6 months without movement recurrence 2
- Complete resolution occurs in most patients with or without treatment 3
Surgical Intervention
Reserve pallidotomy or deep brain stimulation for the minority of patients with severe, persistent, disabling hemiballismus that fails medical management 1, 3
- Surgical treatment targets the internal segment of the globus pallidus, where abnormal neuronal firing patterns are believed to generate the movements 1
- This option should only be considered after exhausting medical therapies and confirming the movements significantly impair quality of life 1, 3
Critical Pitfalls to Avoid
- Do not assume hemiballismus carries a universally poor prognosis—this outdated belief may lead to overly aggressive or premature surgical intervention when medical management and treatment of the underlying cause would suffice 2, 3
- Do not overlook nonketotic hyperglycemia as a reversible cause, especially in patients without obvious stroke on initial imaging 1, 3
- Do not continue neuroleptic therapy indefinitely without reassessment—attempt withdrawal after 3-6 months of symptom control, as many patients will not experience recurrence 2