What is the treatment for a patient with hemiballismus?

Treatment of Hemiballismus

Start with dopamine receptor blockers as first-line pharmacologic therapy, specifically haloperidol or tetrabenazine, and reserve surgical intervention (pallidotomy) only for severe, persistent, disabling cases that fail medical management. 1

Initial Management Approach

Address the Underlying Cause First

• Identify and treat the etiology immediately, as stroke is the most common cause, followed by nonketotic hyperglycemia and HIV-related complications 1
• Check blood glucose levels urgently, as hyperglycemic states are increasingly recognized triggers 1
• Obtain neuroimaging to localize the lesion (typically subthalamic nucleus, though other basal ganglia structures are frequently involved) 1

Observation Period

• Many patients experience spontaneous improvement or complete remission depending on the underlying cause 1
• The natural history of vascular subthalamic lesions typically shows gradual disappearance within days to weeks 2
• However, do not delay treatment in severe cases, as historical reports document death from exhaustion within 4-6 weeks in untreated patients 2

Pharmacologic Treatment

First-Line Agents: Dopamine D2 Receptor Blockers

Haloperidol is the traditional first-line medication for symptomatic control 1, 2

• Use low-dose haloperidol to minimize extrapyramidal side effects 3
• Effective in reducing both amplitude and frequency of involuntary movements 3
• Monitor closely for adverse effects, particularly in elderly patients 2

Alternative in elderly patients: Sulpiride should be considered as first choice due to lesser side effects compared to haloperidol 2

Second-Line Agent: Tetrabenazine

• Tetrabenazine is an effective alternative dopamine-depleting agent 1, 4
• Particularly useful when combined with other modalities for complex presentations 4

Atypical Antipsychotics

Olanzapine represents a valuable alternative when traditional agents fail 5

• One case demonstrated dramatic reduction in hemiballistic movements: upper extremity movements decreased from 23.5 to 3.0 per session, and lower extremity from 20.5 to 7.0 per session during standardized tasks 5
• Also addresses associated agitation effectively 5

Adjunctive Therapy: Chemodenervation

• Botulinum toxin injection can be used for focal control, especially when dystonia coexists with hemiballismus 4
• Provides targeted reduction of specific muscle groups contributing to disability 4

Surgical Treatment

Pallidotomy

• Reserve for the minority of patients with severe, persistent, disabling hemiballismus that fails medical management 1
• Targets abnormal neuronal firing patterns in the internal segment of the globus pallidus, which is implicated in the pathogenesis 1
• Only consider after exhausting pharmacologic options 1

Rehabilitation Considerations

• Acute inpatient rehabilitation should be initiated concurrently with pharmacologic treatment 3
• Combination of medication and rehabilitation leads to substantial functional gains 3
• Quantify improvement using standardized functional tasks to guide treatment adjustments 5

Prognosis

Contrary to older literature, hemiballismus generally has a relatively good prognosis 1

• Lesions outside the subthalamic nucleus tend to persist longer and require more intensive treatment 2
• Vascular causes typically resolve more quickly than other etiologies 2