Anaesthetic Management of a High-risk Patient with Chronic Post-stroke Chorea undergoing Forearm Surgery: A Case Report

Movement disorders such as chorea represent a significant challenge in anaesthetic practice due to involuntary movements, airway concerns, and associated co-morbidities, particularly when secondary to Cerebrovascular Accidents (CVA). The present case reports a 53-year-old male having chronic post-stroke choreiform movements, uncontrolled hypertension, chronic alcoholism and a potentially difficult airway, who presented with fractures of the left radius and ulna requiring surgical fixation. Neurological evaluation revealed generalised choreiform movements with ballistic components (Abnormal Involuntary Movement Scale (AIMS) score 14), likely secondary to chronic basal ganglia involvement. Neuroimaging showed features suggestive of chronic small vessel ischaemic disease without evidence of acute intracranial pathology. The patient was classified as American Society of Anaesthesiologists (ASA) physical status IV, rendering general anaesthesia high-risk because of aspiration risk, airway concerns along with potential exacerbation of involuntary movements. Ultrasound-guided supraclavicular and axillary brachial plexus blocks were performed to provide surgical anaesthesia. Persistent choreiform movements required carefully titrated monitored anaesthesia care using low-dose propofol while also maintaining spontaneous ventilation, airway reflexes. The procedure was completed successfully without any intraoperativepostoperative neurological deterioration or major complications. The uniqueness of this case lies in the successful use of peripheral nerve blocks despite persistent involuntary movements and the observed transient modulation of chorea following propofol sedation. This case underscores the importance of individualised anaesthetic planning, cautious drug selection as well as the role of regional anaesthesia with minimal sedation in managing high-risk patients with chronic post-stroke chorea undergoing peripheral surgery.