Spectacular shrinking deficit followed by delayed Hemichorea-Hemiballismus: Redefining the stroke-TIA spectrum

Abstract

Spectacular shrinking deficit (SSD) is an exceptionally rare cerebrovascular phenomenon defined by the rapid and near-complete resolution of severe neurological deficits following major hemispheric ischemia. We present the first documented case of SSD manifesting as hemichorea-hemiballismus syndrome—a striking and clinically distinct presentation that challenges current understanding of stroke sequelae. A 59-year-old diabetic female developed violent, involuntary left-sided movements one week after transient left hemiplegia, which resolved spontaneously. Neuroimaging revealed T1 hyperintensities in the right striatum without contrast enhancement, subtle diffusion abnormalities, and focal right MCA stenosis, while metabolic workup ruled out hyperglycemic chorea. The patient's refractory symptoms responded uniquely to tetrabenazine, further supporting an ischemic rather than metabolic etiology. • First report of spectacular shrinking deficit causing hemichorea-hemiballismus. • Movement disorder emerged one week after transient hemiplegia resolved. • Normoglycemia at onset rules out hyperglycemic chorea, supporting ischemic etiology. • MRI showed delayed striatal T1 hyperintensity, a known hallmark of SSD. • Symptoms were refractory to neuroleptics but responsive to tetrabenazine.