Hemidystonia secondary to carotid artery gunshot injury

A 9-year-old boy was accidentally shot at close range with a pistol. The bullet entered through the left anterior neck and severed the left common carotid artery. Emergency surgery was performed with an end-to-end anastomosis. He recovered gradually from severe right-sided hemiparesis. CT scans demonstrated left parietal infarction. Within months he developed right hemidystonia, which progressed over the next few years. The movement disorder was refractory to medical therapy. MR scans showed a large demarcated defect in the left parietal lobe extending to the occipital lobe, to the insula and to the posterior ventral putamen. At age 18 the patient underwent a staged left-sided thalamotomy. The hemidystonia improved postoperatively but later partially recurred.