• Peter S Tatum, Joshua Kornbluth, and Andrew Soroka.
• TUFTS Medical Center Department of Neurology, Boston, MA 02116, USA.
• Mil Med. 2021 Nov 10.

AbstractThis report examines the etiology of hemiballistic movements that began 24 hours after a 63-year-old male with vascular risk factors received tissue plasminogen activator (tPa) and thrombolysis in cerebral ischemia 3 (TICI3) thrombectomy for a left middle cerebral artery (MCA) ischemic stroke. The clinical course was reviewed from an admission at a large academic institution where assessments included physical exams, head and neck computed tomography angiography (CTA), and head magnetic resonance imaging (MRI) without contrast. The patient's initial physical exam was consistent with a left MCA syndrome and included a National Institute of Health Stroke Scale (NIHSS) of 20. CTA showed an embolic M2 occlusion. After tPA and TICI 3 thrombectomy, NIHSS improved to 3 for dysarthria, facial weakness, and language deficits. MRI showed left insular diffusion restriction. New right-sided hemiballistic movements began 24 hours after treatment. At his six-week follow-up outpatient appointment, the movements were no longer present, and his neurologic exam was unremarkable, including an NIHSS of zero. No prior cases of hemiballism have been reported as a likely complication of treatment with tPa and thrombectomy. The globus pallidus is the suspected origin of the ballistic movements either from a decreased insular signal or embolic event during treatment. As stroke interventions improve, the susceptibility of certain tissues to brief ischemic events during treatment must be assessed.© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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