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Movement Disorders

Limb to Cranial Overflow Dystonia in a Patient After Stroke

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1 Credit CME

JAMA Neurology

Published Online: March 6, 2023

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Article Information and Disclosures

Arka Prava Chakraborty, MBBS, MD (Medicine), DM (Neurology)¹;

Adreesh Mukherjee, MBBS, MD (Medicine), DM (Neurology)¹;

Atanu Biswas, MBBS, MD (Medicine), DM (Neurology)¹

Author Affiliations

¹Movement Disorders Clinic, Department of Neurology, Institute of Post Graduate Medical Education & Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India

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A 62-year-old man with diabetes and hypertension with history of left putaminal hemorrhage and right hemiparesis 1.5 years ago presented to our movement disorders clinic with progressive dystonia and spasticity of the right upper and lower limbs for 8 months. The patient noticed that whenever he tried to hold a pen or a spoon with his right hand mainly using the thumb and index finger, he had involuntary opening of his mouth, which subsided on resting the hand. This was described as a jaw-opening oromandibular dystonia (OMD) overflowing from the hand dystonia. Chewing movements made by the patient led to the exacerbation of dystonia in the right hand (Video). Magnetic resonance imaging revealed slitlike encephalomalacic focus with hemosiderin deposition in left basal ganglia denoting sequelae of hemorrhage (Figure). The patient was treated with oral antidystonia treatment with trihexyphenydyl, clonazepam, and baclofen and later with botulinum toxin for the hand dystonia and showed some improvement in symptoms.

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Article Information

Corresponding Author: Atanu Biswas, MBBS, MD (Medicine), DM (Neurology), Movement Disorders Clinic, Department of Neurology, Institute of Post Graduate Medical Education & Research (IPGME&R) and Bangur Institute of Neurosciences, 52/1A, SN Pandit Street, Bhowanipur, Kolkata, West Bengal 700025, India (atabis@gmail.com).

Published Online: March 6, 2023. doi:10.1001/jamaneurol.2023.0058

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Bansil S , Prakash N , Kaye J , et al. Movement disorders after stroke in adults: a review. Tremor Other Hyperkinet Mov (N Y). 2012;2:tre-02-42-195-1. doi:10.7916/D86W98TB PubMed Google Scholar

Sitburana O , Jankovic J . Focal hand dystonia, mirror dystonia and motor overflow. J Neurol Sci. 2008;266(1-2):31-33. doi:10.1016/j.jns.2007.08.024 PubMed Google Scholar Crossref

Chen YT , Li S , Magat E , Zhou P , Li S . Motor overflow and spasticity in chronic stroke share a common pathophysiological process: analysis of within-limb and between-limb EMG-EMG coherence. Front Neurol. 2018;9:795. doi:10.3389/fneur.2018.00795 PubMed Google Scholar Crossref

Singhvi Jeenendra , Singh Amit Shankar , Junaid Syed . Jaw opening oromandibular dystonia following acute stroke: analysis and review. Neurology Apr. 2019;92(15 Supplement):4.8-017. https://n.neurology.org/content/92/15_Supplement/P4.8-017 Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.