LESIONS

A Guide to Localisation in Neurology

Case 16 - Involuntary movements

Case

A 69 year old woman presented with new involuntary movements on her left side.

She had been well the night before, then had awoken with these, and they had been non-stop for the last 4 hours. She had no ability to suppress them. They affected the leg and the arm and caused her to constantly shift position. Her right side was normal.

She had no headache, was fully alert and reported no cognitive symptoms, and had no issues with speech, vision, hearing, sensation or strength in the limbs – she could still grip items in her left, but the movements made it impossible to control them, and she also could not sustain a grip as her hand would sometimes randomly open and release the object.

It was very difficult to walk due to the movements in her left leg although she still had the strength to stand, but had fallen twice and not reattempted walking. Getting dressed that morning had been very challenging and took several minutes.

In addition the skin over her elbow and forearm had become irritated and red from rubbing against the couch armrest and her clothes.

She had a history of hypertension, elevated cholesterol and type II diabetes. She was a former smoker. She had no history of neurological disease.

On examination she had:

• Continuous, random, fidgety movements in the left arm and leg, involving different muscles and joints and without any pattern. At times these were twisting and writhing, e.g. hand wringing, finger movements and rolling the ankle; and at others, more violent, as if she were punching, kicking, or throwing a projectile
• Similar shifting movements in the trunk, with the appearance of having the inability to sit still
• Random brief movements around the neck such as elevating the shoulder, and some right facial movements (e.g. briefly grimacing)
• Power was normal, but she would release her grip after a 1-2 seconds, and it was difficult to test strength as she could not sustain contraction

It wasn't possible to test tone as she couldn't relax the limb, nor coordination as she she couldn't direct it towards any target due to the constant movements.

She was alert, fully orientated, and there were no cranial nerve deficits, problems with speech or any sensory abnormalities. Observations were normal bar blood pressure of 190/95mmHg.