Chorea, Athetosis, and Hemiballismus

(See also Overview of Movement and Cerebellar Disorders Overview of Movement and Cerebellar Disorders Voluntary movement requires complex interaction of the corticospinal (pyramidal) tracts, basal ganglia, and cerebellum (the center for motor coordination) to ensure smooth, purposeful movement... read more .)

Chorea and athetosis are defined by clinical manifestations; many experts believe that when they occur together (as choreoathetosis), athetosis is a dystonia superimposed on chorea. Chorea and athetosis result from impaired inhibition of thalamocortical neurons by the basal ganglia. Excess dopaminergic activity may be the mechanism.

Clinicians should seek and treat the cause of chorea whenever possible.

Huntington disease Huntington Disease Huntington disease is an autosomal dominant disorder characterized by chorea, neuropsychiatric symptoms, and progressive cognitive deterioration, usually beginning during middle age. Diagnosis... read more is the most common degenerative disorder causing chorea. In Huntington disease, drugs that suppress dopaminergic activity, such as antipsychotics Antipsychotic Drugs Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more (eg, risperidone, olanzapine), and dopamine-depleting drugs (eg, deutetrabenazine, reserpine [no longer available in US], tetrabenazine) can be used to treat chorea. Antipsychotics may also help by lessening the neuropsychiatric symptoms commonly associated with Huntington disease (eg, impulsivity, anxiety, psychotic behavior). However, improvement may be limited and transient. All of these drugs may be judiciously used to treat choreas without a definable cause.

Other causes of chorea include

Sydenham chorea CNS can occur in rheumatic fever and may be the first symptom of it. A tumor or an infarct in the striatum (caudate or putamen) can cause acute unilateral chorea (hemichorea) on the opposite side of the body. Sydenham chorea and chorea due to infarcts of the caudate nucleus often lessen over time without treatment.

Chorea due to hyperthyroidism or another metabolic cause (eg, hyperglycemia) usually lessens over time when thyroid function or blood glucose returns to normal. If chorea does not subside after several weeks of metabolic control, clinicians should check for another cause such as stroke.

Chorea in patients > 60 should not be assumed to be senile chorea but should be thoroughly evaluated to identify the cause (eg, toxic, metabolic, autoimmune, paraneoplastic, drug-induced).

Chorea gravidarum occurs during pregnancy, often in patients who have had rheumatic fever. Chorea usually begins during the 1st trimester and resolves spontaneously at or after delivery. If treatment before delivery is necessary because chorea is severe, barbiturates are indicated because they have fewer fetal risks than other drugs used to manage chorea. Rarely, a similar disorder occurs in women taking oral contraceptives.

Hemiballismus is caused by a lesion, usually an infarct, in or around the contralateral subthalamic nucleus. Although disabling, hemiballismus is usually self-limited, lasting 6 to 8 weeks. If severe, it can be treated with an antipsychotic for 1 to 2 months or, if antipsychotics are ineffective, with deep brain stimulation.