Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases

Bilateral chorea/ballismus: detection and management of a rare complication of non-ketotic hyperglycaemia

Non-ketotic hyperglycaemia (NKH) is the most common metabolic cause of hemichorea-hemiballismus (HC-HB) and an often-reversible condition. A 68-year-old man presented to the emergency department with a severe hyperglycaemic episode and altered mental status. He was treated appropriately and discharged home after his blood glucose levels were normal with an improvement of mental status. Four weeks after the discharge, he returned with flailing movements of bilateral upper and lower limbs. MRI of the brain revealed hyperintensities of the bilateral putamen on T1-weighted imaging. The patient's symptoms improved with a combination of amantadine, clonazepam and tetrabenazine. Several hypotheses involving gemistocytes, calcification and petechial haemorrhage were proposed in support of imaging abnormalities in the striatum. Dopamine-depleting agents and neuroleptics are used in the treatment of chorea. It is recommended to try a dose of tetrabenazine in patients with NKH-induced HC-HB if no improvement is appreciated with initial treatment of glycaemic control.

Paediatric non-ketotic hyperglycaemic hemichorea-hemiballismus

Non-ketotic hyperglycaemic hemichorea-hemiballismus (NHHH) is commonly seen among elderly Asian women with type 2 diabetes mellitus. Here, we present a case of a 16-year-old Filipina with type 1 diabetes mellitus who is poorly compliant to her medications and subsequently developed right hemichorea-hemiballismus (HH). She was initially admitted with hyperglycaemia but was negative for ketonuria or metabolic acidosis. Neuroimaging showed bilateral lentiform nuclei and left caudate hyperdensities on CT and T1-weighted hyperintensity on MRI. Blood glucose was controlled with insulin. Haloperidol and clonazepam were started for the HH with gradual resolution of symptoms in 6 weeks. This is the fifth reported case of NHHH seen among the paediatric age group. NHHH in the paediatric population is clinically and radiographically similar to NHHH seen among adults. Correction of hyperglycaemia results in clinical improvement and radiographic resolution of lesions but persistent cases may necessitate specific treatment targeted towards the abnormal movements.

Hemichorea after hyperglycemia correction: A case report and a short review of hyperglycemia-related hemichorea at the euglycemic state

RATIONALE

Hyperglycemic hemichorea tends to affect elderly patients with type 2 diabetes, women, and the Asian population. The onset of involuntary movement typically occurs at the hyperglycemic state and subsides at the euglycemic state. In this report, we present an unusual case that developed delayed-onset hemichorea after hyperglycemia correction.

PATIENT CONCERNS

A 70-year-old man was admitted to neurology ward with symptoms of subacute dizziness. Hyperglycemia and high level ketone body was incidentally noted. Hemichorea occurred in his left limbs 2 days after hyperglycemia correction.

DIAGNOSES

Patient remained conscious, and no other focal neurological deficits were noted while hemichorea occurred. Blood test revealed no contributory cause. Brain magnetic resonance imaging revealed no lesions in the putamen or subthalamus. A diagnosis of probable hyperglycemia-related hemichorea was made.

INTERVENTIONS

Haloperidol (2 mg, 3 times per day) was prescribed.

OUTCOMES

Hemichorea improved gradually before discharge and resolved 4 months later.

LESSONS

Differential diagnosis of hemichorea should include delayed-onset hemichorea after hyperglycemia correction.

Persistent Hemichorea and Caudate Atrophy in Untreated Diabetic Striatopathy: A Case Report

Background

Neurological complications of diabetes and hyperglycemia are relatively common but the specific manifestations can vary widely. Diabetic striatal disease or “diabetic striatopathy” is an uncommon condition usually thought to result from hyperglycemic injury to the basal ganglia, producing a hyperkinetic movement disorder, usually choreiform in nature. Symptoms are generally reversible with treatment of the hyperglycemia.

Case Description

We report the case of a 57-year-old woman presenting with a unilateral choreoathetosis of the left upper extremity, persistent for 4 years. Contemporaneous imaging demonstrated severe atrophy of the right caudate nucleus, while imaging obtained at the onset of symptoms was consistent with a right diabetic striatopathy. Symptoms improved with the use of dopamine antagonists and benzodiazepines.

Conclusion

Although generally considered to be fully reversible, this case demonstrates that diabetic striatopathy can result in permanent structural lesions with persistent symptoms if left untreated.

Globus Pallidus Internus Deep Brain Stimulation for Disabling Diabetic Hemiballism/Hemichorea

Unilateral hemichorea/hemiballism (HH) associated with contralateral neuroimaging abnormalities of the basal ganglia, which is characterized by T1 hyperintensity on magnetic resonance imaging (MRI) and is secondary to diabetic nonketotic hyperglycemia, is a rare and unique complication of poorly controlled diabetes mellitus (DM). Although almost all prior reports have documented rapid resolution of HH within days after normalization of blood glucose levels, medically refractory persistent HH has been noted. The experience of surgical intervention for persistent HH is limited. A 46-year-old, right-handed female patient with type 2 DM presented with refractory diabetic HH on the left side of 6 months' duration despite DM control and neuroleptic medication usage. Image-guided deep brain stimulation (DBS) on the right globus pallidus internus (GPi) was performed. A mechanical micropallidotomy effect was observed and chronic stimulation of GPi was quite effective in symptomatic control of diabetic HH until a 16-month follow-up visit. DBS of the GPi can be an effective treatment for medically refractory diabetic HH.

Diabetic striatopathy manifesting as severe consciousness disturbance with no involuntary movements

BACKGROUND

Diabetic striatopathy, one of the complications of diabetes mellitus, is characterized by involuntary movements, including hemichorea and hemiballismus, and the presence of hyperintense lesions on T1-weighted magnetic resonance imaging of the striatum.

CASE REPORT

We present a case of diabetic striatopathy manifesting as severe consciousness disturbance without chorea or ballismus. A 58-year-old man was admitted to our hospital in a state of unconsciousness. He was diagnosed with diabetic striatopathy as a result of extremely elevated blood glucose levels and typical magnetic resonance imaging findings in the left striatum, although involuntary movements were absent. He was treated with insulin, and his glucose levels were well maintained. His neuropsychiatric symptoms recovered, rather slowly but completely, after ~20 days.

CONCLUSION

This case indicates the diversity of striatal dysfunction induced by hyperglycaemia. For good prognosis of diabetic striatopathy, prompt diagnosis and appropriate treatments are important. Physicians should be aware that this disease can cause various neurological and psychiatric symptoms other than chorea or ballismus.

Chorea associated with nonketotic hyperglycemia: A case report with atypical imaging changes

INTRODUCTION

This is a unique case of nonketotic hyperglycemic (NKH) chorea in 84-year-old Asian woman. The patient had a history of type 2 diabetes mellitus more than 30 years, but had a poor control of blood sugar. She complained of acute onset of bilateral limb involuntary activities, and being easy to fall within a week. Laboratory testing disclosed hyperglycemia (669 mg/dL), glycated hemoglobin (14%), and normal ketones. The brain computed tomography scan and magnetic resonance imaging did not disclose any abnormality in the basal ganglion unlike most cases. The patient was then diagnosed with NKH chorea. Her symptoms improved quickly.

CONCLUSIONS

NKH chorea with normal imaging may represent a new subtype.

Case report of hyperglycemic nonketotic chorea with rapid radiological resolution

BACKGROUND

Hemichorea is a rare manifestation of nonketotic hyperglycemia that usually affects elderly Asian women with poor glycemic control. Non-contrast computerized Tomography and T1- weighted Magnetic Resonance Imaging shows characteristic hyperintense basal ganglia lesions.

CASE PRESENTATION

A Fifty-seven year old Sri Lankan female presented with a two-day history of right upper limb chorea. She had been diagnosed with diabetes mellitus one year ago, but was not on any treatment and did not have any micro vascular or macro vascular complications. Random blood sugar was 420 mg/dl and full blood count, liver function tests, renal function tests, inflammatory markers, thyroid function tests, Urine protein / creatinine ratio, electrocardiogram and 2D Echo were normal. Arterial blood gas did not show acidosis and ketone bodies were not detected in urine. Non-contrast computerized Tomography brain on day 1 showed left side hyperdense lentiform and caudate nuclei and MRI on day 3 showed slightly high signal intensity of left side basal ganglia on T1- weighted images and low signal intensity on T2-weighted and Fluid-attenuated inversion recovery images. She was started on insulin and a low dose of clonazepam and glycemic control was achieved on day 3. Two days later, the chorea completely disappeared. CT brain was repeated 4 days and 10 days following glycemic control, which showed rapid resolution of CT changes. Clonazepam was stopped in 2 weeks and chorea did not recur.

CONCLUSION

This is a rare manifestation of diabetes in Sri lanka and diagnosing this rare entity will direct clinicians to achieve optimum glycemic control as the treatment which will lead to rapid clinical response without any other medications. In this case report we high light that with the clinical improvement, repeating a CT scan even after a very short period like 2 weeks will show rapid radiological resolution. This repeat imaging can also be useful to confirm the diagnosis, which will minimize unnecessary investigations and treatments. Further cases of hyperglycemic nonketotic chorea with brain imaging performed within short intervals is needed to evaluate the nature of rapid radiological changes, which will be useful to understand the pathology of this condition.

Radiographic basal ganglia abnormalities secondary to nonketotic hyperglycemia with unusual clinical features

A 77-year-old woman was admitted to a local clinic for altered consciousness and presented with a suspected basal ganglion hemorrhage detected on brain computed tomography. The patient was stuporous, but her vital signs were stable. Her initial blood glucose was 607 mg/dL, and a hyperdense lesion was found in the right basal ganglion on brain computed tomography. T1-weighted magnetic resonance imaging revealed high signal intensity in the right basal ganglion. Electroencephalography showed no seizure activity. The patient was treated with a fluid infusion, and serum glucose level was controlled with insulin. The patient gradually recovered consciousness and was alert within 24 hours as serum glucose level normalized. The basal ganglion lesion caused by hyperglycemia was not accompanied by involuntary limb movement. This is the first report of a patient presenting with decreased consciousness and typical neural radiographic changes associated with nonketotic hyperglycemia but without movement abnormalities.

Reversible striatal hypermetabolism in chorea associated with moyamoya disease: a report of two cases

BACKGROUND

The pathophysiological mechanism of chorea as a presentation of pediatric moyamoya disease remains unknown, although ischemia is suspected as a likely cause. The authors describe two cases of pediatric moyamoya disease, both of which presented with hemichorea in the stable phase after successful bypass surgery.

CLINICAL PRESENTATION

Cerebral blood flow was almost normal in one case and decreased in the basal ganglia and watershed area in the other case due to infarcts occurring before surgery. In both cases, ¹⁸F-fluorodeoxyglucose positron emission tomography revealed elevated glucose metabolism in the corresponding side of the striatum, which reverted to normal after recovery from chorea. Magnetic resonance angiography revealed a dilated and extended lenticulostriate artery at the exact site of the hypermetabolic lesion.

Diabetic striatopathy-Does it exist in non-Asian subjects?

BACKGROUND

Diabetic striatopathy (DS) is a rare complication of diabetes mellitus (DM). The syndrome appears in patients with uncontrolled DM and is characterized by abrupt onset of movement disorder, mainly hemichorea and accompanied by specific findings on brain imaging. It is believed that DS is unique to the Asian population and affects mainly elderly women with uncontrolled DM.

METHODS

In order to define existence and characterization of DS in Western population, we reviewed the medical records of all patients admitted to the Chaim Sheba Medical Center between 2004 and 2014 and identified those with documented elevated HbA1c (>10%). The charts and imaging studies of those with elevated HbA1c and undiagnosed neurological symptoms were reviewed to diagnose DS.

RESULTS

Out of 697 patients with HbA1c>10%, 328 patients had unknown neurological diagnosis. Among them, we identified 4 patients (3 women, mean age 73 and mean HbA1c of 14.8%) with hemichorea or choreoathetosis and brain imaging findings compatible with the diagnosis of DS. Only one out of the 4 patients was diagnosed during hospitalization with DS. All patients were treated with insulin with improvement of their symptoms during hospitalization. However, there was a recurrence in 2 of them and 1 died during the second episode.

CONCLUSION

Diabetic striatopathy exists but underdiagnosed in the Western population. It is important to increase the awareness for this clinical syndrome in order to treat those patients properly.

Irreversible Hemichorea-Hemiballism in a Case of Nonketotic Hyperglycemia Presenting as the Initial Manifestation of Diabetes Mellitus

Background

Hemichorea–hemiballism (HCHB) is a hyperkinetic movement disorder with features of both chorea and ballism occurring on the same side.

Case report

We present a case of HCHB due to nonketotic hyperglycemia (NKH) that was the initial presentation of diabetes and was irreversible clinically even after 6 months of optimal blood sugar control.

Discussion

Although HCHB due to hyperglycemia is a potentially reversible condition in the majority of patients, prolonged uncontrolled hyperglycemia may cause ischemic insult and persistent symptoms. Hyperglycemia should always be kept in the list of differentials while dealing with patients who are newly diagnosed with HCHB.

Acute hemichorea in a newly diagnosed type II diabetes patient: a diagnostic challenge in resource-limited setting: a case report

BACKGROUND

Chorea is a rare complication of uncontrolled type II diabetes. We report for the first time in Tanzania a case of type II diabetes presenting with a hyperglycaemia-induced hemichorea.

CASE PRESENTATION

A 58-year-old Tanzanian chagga by tribe with a body mass index of 28 kg/m(2) and newly diagnosed type II diabetes presented with polydipsia and involuntary movements of the right upper limb for 4 days. His plasma glucose was 549 mg/dl and glycated haemoglobin was 18.9 %. His movements were exaggerated by attempts to use his right hand. The rest of his neurological assessment was unremarkable. Other laboratory findings including calcium were within the normal range. A computed tomography scan of the brain was essentially normal except for age-related atrophy. There was no significant ketonuria on urine dipstick testing. We treated the patient's hyperglycaemia with intravenous insulin and the dystonia disappeared within 5 days.

CONCLUSION

Hemichorea is among the rare complications of hyperglycaemia-induced involuntary movements. Hyperglycaemia should be considered as a differential diagnosis for patients with type II diabetes mellitus presenting with hemichorea upon clinical assessment.

Hemichorea/Hemiballism Associated with Hyperglycemia: Report of 20 Cases

Background

Hemichorea/hemiballism associated with nonketotic hyperglycemia is a well-recognized syndrome, but few case series have been reported in the literature.

Case Report

We describe 20 patients with hemichorea/hemiballism associated with hyperglycemia (9 males and 11 females) with mean age of 67.8 years. Ten patients had a previous diagnosis of type 2 diabetes mellitus, and one had type 1 diabetes mellitus. Six of them had documentation of poor diabetic control over at least the last 3 months. Nine patients had new-onset hyperglycemia with a diagnosis of diabetes mellitus made after discharge. Seventeen patients had unilateral chorea/ballism, while three had bilateral chorea/ballism. Eighteen cases had striatal hyperdensities on computed tomography (CT) and/or hyperintense signals on magnetic resonance imaging (MRI). The putamen was affected in all cases, and the caudate nucleus was involved in nine.

Discussion

Hemichorea/hemiballism associated with nonketotic hyperglycemia can be the presenting sign of diabetes mellitus in almost half of cases or can occur after a few months of poor glycemic control in patients with diagnosed diabetes. This case series is one of the largest to date and adds valuable information about clinical and neuroimaging features that are comparable with published data but also emphasize the role of adequate diabetes mellitus control.

Glycemic and vascular choreoballism as main causes of secondary choreoballism involving the putamen

BACKGROUND

The putamen is frequently involved in cases of secondary choreoballism (CB). To date, no study has investigated clinical features of secondary CB such as vascular CB (vCB) and glycemic CB (gCB) in view of putaminal involvement.

OBJECTIVES

Cases of CB with putaminal lesions from our hospital were identified in hospital records. Historical cases were obtained from the MEDLINE database. Cases of gCB are defined as those with CB, diabetes mellitus and high signal intensities (HSIs) in the putamen on T1 weighted imaging (T1WI). Cases of vCB are identified among those with CB and stroke involving the putamen.

RESULTS

A total of 284 cases (in-hospital cases, 11 gCB and 3 vCB; historical cases, 225 gCB and 45 vCB) were included after excluding 23 glycemic cases without HSIs on T1WI and 53 cases with non-glycemic etiologies. Persistence of CB was longer than one month in 84 cases (gCB, 36.9%, and vCB, 63.0%). Extra-putaminal lesions occurred more frequently in vCB (71.1%) than gCB (50.7%). Age, cerebrovascular etiology and extra-putaminal lesions were found to be significant predictors for persistence of CB one month after onset. Female gender and extra-putaminal lesions were significant predictors for persistence of CB one year after onset.

CONCLUSIONS

gCB was the primary common cause of secondary CB involving the putamen. Older age, female gender, vascular etiologies and extensive lesions (putaminal and extra-putaminal) were significant predictors of CB persistence.

CT and MR Unilateral Brain Features Secondary to Nonketotic Hyperglycemia Presenting as Hemichorea-Hemiballism

Hemichorea-hemiballism is an unusual hyperkinetic movement disorder characterized by continuous involuntary movements of an entire limb or both limbs on one side of the body. The acute onset of this disorder occurs with an insult in contralateral basal ganglia. Ischemic events represent the most common cause. Nonketotic hyperglycemia comes in second place. Nonketotic hyperglycemic hemichorea-hemiballism (NHH) is a rare cause of unilateral brain abnormalities on imaging studies confined to basal ganglia (mainly putaminal region as well as caudate nucleus). Subtle hyperdensity in striatal region can be found on CT studies whereas brain MR imaging typically shows T1 hyperintensity and T2 hypointensity in the basal ganglia contralateral to the movements. Diagnosis is based on both glucose levels and neuroimaging findings. Elevated blood glucose and hemoglobin A1c levels occur with poorly controlled diabetes. In this case report, our aim is to present neuroimaging CT and MR unilateral findings in an elderly woman secondary to nonketotic hyperglycemia presenting as hemichorea-hemiballism.

Network localization of hemichorea-hemiballismus

OBJECTIVE

To determine whether neuroanatomically heterogeneous strokes causing hemichorea-hemiballismus localize to a common functional network.

METHODS

We identified 29 cases of lesion-induced hemichorea-hemiballismus from the literature and mapped each lesion volume onto a reference brain. Using a recently validated technique termed lesion network mapping, we tested whether these lesions belonged to the same functional network. To accomplish this, the network of brain regions functionally connected to each lesion was identified using a connectome dataset from healthy participants. Network maps were overlapped to identify any region functionally connected to our set of lesions. Specificity was evaluated using a case-control design; control cohorts included a group of similar lesions randomized to different brain locations and a second group of lesions causing a separate movement disorder, asterixis. Reproducibility was evaluated using an independent cohort of 10 additional hemichorea-hemiballismus cases.

RESULTS

Lesions showed heterogeneity in anatomical location, consistent with prior reports. However, at least 90% of these lesions showed network overlap in the posterolateral putamen. This result was specific to lesions causing hemichorea-hemiballismus and reproducible in an independent cohort. The putaminal overlap site was itself connected to a broader motor network that predicted the distribution of lesions causing hemichorea-hemiballismus.

CONCLUSIONS

Strokes causing hemichorea-hemiballismus, while anatomically heterogeneous, localize to a common functional network. Specifically, lesions occur in regions functionally connected to the posterolateral putamen, a region previously implicated in hyperkinetic movement disorders. Lesion network mapping may be useful in identifying the neuroanatomical substrates of heterogeneous lesion-based disorders.

Abnormal movements in critical care patients with brain injury: a diagnostic approach

Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.

Hemichorea with unilateral MRI striatal hyperintensity in a Saudi patient with diabetes

Hemichorea is a disorder characterized by abnormal, continuous, nonrhythmic, jerky, and distal movement involving one side of the body. It may result from cerebrovascular insult to basal ganglia, or from other causes including neoplasm, infection, and non-ketotic hyperglycemia. We report the clinical, laboratory, and neuroimaging data with treatment response of a Saudi woman who has diabetes with left side hemichorea, involving the face, and upper and lower extremities, with unilateral right striatal hyperintense signal changes in T1 weighted MRI, and a hyperglycemic state of longstanding uncontrolled diabetes. Literature review suggested a syndrome with a triad of symptoms: non-ketotic hyperglycemia, hemichorea, and T1 MRI striatal hyperintensities. As the number of internationally reported cases is still modest, reporting more patients will highlight aspects pertaining to the diagnosis and treatment of this condition. We present a patient who had a sustained therapeutic result from haloperidol and clonazepam.

Post-stroke dyskinesias

Strokes, whether ischemic or hemorrhagic, are among the most common causes of secondary movement disorders in elderly patients. Stroke-related (vascular) movement disorders, however, are uncommon complications of this relatively common disease. The spectrum of post-stroke movement disorders is broad and includes both hypo- and hyperkinetic syndromes. Post-stroke dyskinesias are involuntary hyperkinetic movements arising from cerebrovascular insults and often present with mixed phenotypes of hyperkinesia which can sometimes be difficult to classify. Nevertheless, identification of the most relevant motor phenotype, whenever possible, allows for a more specific phenomenological categorization of the dyskinesia and thus helps guide its treatment. Fortunately, post-stroke dyskinesias are usually self-limiting and resolve within 6 to 12 months of onset, but a short-term pharmacotherapy might sometimes be required for symptom control. Functional neurosurgical interventions targeting the motor thalamus or globus pallidus interna might be considered for patients with severe, disabling, and persistent dyskinesias (arbitrarily defined as duration longer than 12 months).

Higher fasting plasma glucose is associated with striatal and hippocampal shape differences: the 2sweet project

OBJECTIVE

Previous studies have demonstrated associations between higher normal fasting plasma glucose levels (NFG) (<6.1 mmol/L), type 2 diabetes (T2D) and hippocampal atrophy and other cerebral abnormalities. Little is known about the association between plasma glucose and the striatum despite sensorimotor deficits being implicated in T2D. This study aimed to investigate the relationship between plasma glucose levels and striatal and hippocampal morphology using vertex-based shape analysis.

DESIGN

A population-based, cross-sectional study.

SETTING

Canberra and Queanbeyan, Australia.

PARTICIPANTS

287 cognitively healthy individuals (mean age 63 years, 132 female, 273 Caucasian) with (n=261) or without T2D (n=26), selected from 2551 participants taking part in the Personality & Total Health (PATH) Through Life study by availability of glucose data, MRI scan, and absence of gross brain abnormalities and cognitive impairment.

OUTCOME MEASURES

Fasting plasma glucose was measured at first assessment, and MRI images were collected 8 years later. Shape differences indicating outward and inward deformation at the hippocampus and the striatum were examined with FMRIB Software Library-Integrated Registration and Segmentation Toolbox (FSL-FIRST) after controlling for sociodemographic and health variables.

RESULTS

Higher plasma glucose was associated with shape differences indicating inward deformation, particularly at the caudate and putamen, among participants with NFG after controlling for age, sex, body mass index (BMI), hypertension, smoking and depressive symptoms. Those with T2D showed shape differences indicating inward deformation at the right hippocampus and bilateral striatum, but outward deformation at the left hippocampus, compared with participants with NFG.

CONCLUSIONS

These findings further emphasize the importance of early monitoring and management of plasma glucose levels, even within the normal range, as a risk factor for cerebral atrophy.

Corticosteroid induced hyperosmolar hyperglycaemic state and hemiballismus

We present an 89-year-old man with new onset of left-sided hemiballismus affecting his face, arm and leg. He was found to have hyperglycaemia with a glucose level of 20.2 mmol/l and had started prednisolone 3 months earlier for polymyalgia rheumatica. A T₂-weighted magnetic resonance scan of the brain showed a hypointense lesion of the right lentiform nucleus. At follow-up, his symptoms had improved with treatment for diabetes mellitus. To our knowledge, this is the first patient to develop hemiballismus after starting corticosteroids.

Non-ketotic hyperglycemia unmasks hemichorea

Background

Chorea can be caused by a variety of diseases, including neurodegenerative disorders, vascular events, toxic-metabolic states, and immunologic and infectious diseases. We describe a patient who presented with hemichorea as the initial manifestation of Diabetes Mellitus (DM) and responded partially to the glycemic control.

Case report

A 63-year-old, healthy Hispanic man with no prior history of medical illness presented with subacute onset, gradually progressive hemichorea of 6 weeks’ duration. On evaluation, he was found to have non-ketotic hyperglycemia with high serum glucose (328 mg/dL), elevated hemoglobin A1C (9.9%), and absent ketones. Magnetic Resonance Imaging of the brain demonstrated hyper intense signals in bilateral basal ganglia on T1W images. He was diagnosed to have DM. Despite optimal glycemic control with insulin, the patient continued to have hemichorea at 3 months follow-up and required haloperidol for control of the involuntary movements.

Significance

Involuntary movements, particularly hemichorea, can be a manifestation and rarely be a presenting sign of DM.

Hemichorea-Hemiballismus as the First Sign of Type 1b Diabetes During Adolescence and Its Recurrence in the Setting of Infection

Chorea may be secondary to hyperosmolar nonketotic hyperglycemia, but such situation has rarely been described in adolescents, particularly as the initial and single manifestation of type 1 diabetes. We describe a case of a previously healthy 14-year-old girl with sudden onset of choreic movements on her left upper and lower limbs. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed an area of hyperdensity/hyperintensity affecting the right striatum. Blood glucose was 349 mg/dL. Despite adequate glucose control, the involuntary movements persisted and haloperidol, later substituted with valproate, was prescribed, with satisfactory but not complete resolution of the chorea. In 2 other occasions, when the patient had an infection and subsequent hyperglycemia, the chorea relapsed. Although not common, hyperglycemia must be considered in the differential diagnosis of acute hemichorea-hemiballismus in children and adolescents, particularly because it is a potentially reversible cause.

Movement disorders in systemic diseases

Movement disorders, classically involving dysfunction of the basal ganglia commonly occur in neurodegenerative and structural brain disorders. At times, however, movement disorders can be the initial manifestation of a systemic disease. In this article we discuss the most common movement disorders which may present in infectious, autoimmune, paraneoplastic, metabolic and endocrine diseases. Management often has to be multidisciplinary involving primary care physicians, neurologists, allied health professionals including nurses, occupational therapists and less frequently neurosurgeons. Recognizing and treating the underlying systemic disease is important in order to improve the neurological symptoms.

Diabetic striatopathy in a patient with hemiballism

Diabetic striatopathy is a rare and life-threatening manifestation of diabetes mellitus. The disease commonly affects individuals of Asian descent, females, and the elderly. Patients usually present with hemiballism-hemichorea caused by nonketotic hyperglycemia. Hemiballism-hemichorea is defined as involuntary continuous random appearing movement involving one side of the body. This movement disorder may develop secondary to stroke, diabetic striatopathy, neoplasm, infection, Wilson's disease, and thyrotoxicosis. Despite being rare, prompt recognition of a hyperglycemia-induced hemiballism-hemichorea is essential because the symptoms are reversible with correction of hyperglycemia. Diagnosis is possible based on blood analysis and neuroimaging findings. Laboratory tests reveal raised blood glucose and hemoglobin A1C levels which indicate poorly controlled diabetes. Neuroimaging provides suggestive findings of diabetic striatopathy which are hyperattenuation on computed tomography and hyperintensity on T1-weighted magnetic resonance imaging in the basal ganglia. In this case report, our aim is to present neuroimaging findings in an adult man with sudden onset of hemiballism associated with nonketotic hyperglycemia.

Hemichorea-hemiballism: a case report

A 55-year-old woman with type 2 diabetes mellitus presented with abnormal left-sided movements of her arm and leg. Her initial CT scan of head showed a hyperintensity in the right basal ganglia. A 3 T MR scan of brain showed changes consistent with right basal ganglia haemorrhage. We diagnosed hemichorea-hemiballism syndrome. We treated her movement disorder with tetrabenazine and sulpiride and improved her glucose control. After 4 months, she still has mildly abnormal left-sided movements but can function independently again. In this article, we discuss her imaging and review the literature on hemichorea-hemiballism.

Management of hemichorea hemiballismus syndrome in an acute palliative care setting

Hemichorea hemiballismus (HCHB) is a rare and debilitating presentation of hyperglycemia and subcortical stroke. Early identification, proper assessment and management of HCHB can lead to complete symptom relief. We describe a case of HCHB presenting to a palliative care setting. A 63-year-old diabetic and hypertensive lady, with history of ovarian cancer presented to Palliative Medicine outpatient clinic with two days history of right HCHB. Blood investigations and brain imaging showed high blood sugar levels and lacunar subcortical stroke. Blood sugar levels were controlled with human insulin and Aspirin. Clopidogrel and Atorvastatin were prescribed for the management of lacunar stroke. HCHB reduced markedly post-treatment, leading to significant reduction in morbidity and improvement in quality of life. The symptoms completely resolved within one week of starting the treatment and the patient was kept on regular home and outpatient follow up for further monitoring. Acute palliative care (APC) approach deals with the management of comorbidities and their complications along with supportive care. Prompt assessment and management of such complications lead to better patient outcomes.

Hyperglycemia-associated Hemichorea-hemiballism: The Spectrum of Clinical Presentation

Hyperglycemia rarely manifests as hemichorea-hemiballism (HH), which is characterized by simple partial motor seizures. One of the difficulties in the management of hyperglycemia-induced HH is the failure to recognize this entity due to its relatively uncommon presentation. We herein present a case series of hyperglycemia-associated dyskinesias, highlighting the different possible clinical presentations of this entity. Both hyperglycemia and hyperosmolality are probable predisposing factors, while ketoacidosis has a protective role in preventing the dyskinesias. One of our patients had ketotic hyperglycemia leading to HH, a previously unreported finding. Early recognition of this entity is crucial as prompt glycemic control leads to the resolution of symptoms and signs.

Chorea-ballism associated with ketotic hyperglycemia

Chorea-ballism is a rare movement disorder characterized by irregular, poorly patterned, and involuntary movements, which are usually unilateral but may be bilateral or involve the extremities. The most common metabolic cause of transient chorea-ballism is nonketotic or ketotic hyperglycemia (NKHG or KHG, respectively). A meta-analysis and several reviews have identified clinical characteristics of NKHG-associated chorea-ballism; however, the characteristics of KHG-associated chorea-ballism remain unknown. We performed a search for studies of patients with KHG-associated chorea-ballism, published in MEDLINE between 1960 and May 2014, and identified 13 studies of 15 patients. Despite the limited number of cases, we identified some significant differences in the clinical and radiological characteristics between patients with KHG- or NKHG-induced chorea-ballism. Patients with KHG were significantly younger than patients with NKHG, and a higher percentage of patients with KHG had atypical or negative brain imaging findings for chorea-ballism compared to patients with NKHG. We recommend that blood glucose levels be tested on admission as a key diagnostic measure, to improve the early diagnosis of chorea-ballism. The best treatment for KHG-induced chorea-ballism is rapid glucose control with an insulin drip and, possibly, neuroleptics. The mechanisms of the disease are unclear, although the GABA theory, cerebrovascular insufficiency, and alterations of dopaminergic activity in the striatum might play important roles.

Hemiballism-hemichorea induced by ketotic hyperglycemia: case report with PET study and review of the literature

Hemiballism-hemichorea (HB-HC) is commonly used to describe the basal ganglion dysfunction in non-ketotic hyperglycemic elderly patients. Here we report two elderly female patients with acute onset of involuntary movements induced by hyperglycemia with positive urine ketones. We described the computed tomography and magnetic resonance imaging findings in these two patients, which is similar to that of non-ketotic hyperglycemic HB-HC patients. FDG-PET was performed and the glucose metabolism in the corresponding lesion in these two patients was contradictory with each other. We tried to clarify the underlying mechanisms of HB-HC and explain the contradictory neuroradiological findings in FDG-PET as being performed at different clinical stages.

Hemichorea in a patient with diabetic ketoacidosis

BACKGROUND

Chorea is a common presenting feature of metabolic disorders, including nonketotic hyperglycemia in patients with type 2 diabetes mellitus, but rarely has been reported in diabetic ketoacidosis, hypothyroidism and vitamin B12 deficiency.

METHODS

Review the literature for reported cases of chorea as a presenting manifestation in metabolic disorders.

RESULTS

We report a case of hemichorea in a patient with type 2 diabetes mellitus complicated by diabetic ketoacidosis. The patient had a two day history of right sided hemichorea and decreased level of consciousness. Initial laboratory studies revealed hyperglycemia, ketosis and an anion gap metabolic acidosis consistent with diabetic ketoacidosis. Once treatment was started the choreiform movements significantly improved over three weeks.

CONCLUSION

Although DKA has been rarely reported as a trigger for chorea, it should be in the differential diagnosis of a patient presenting with an acute chorea. Given the reversible nature of this disease, early recognition and treatment are imperative.

Unilateral striatal CT and MRI changes secondary to non-ketotic hyperglycaemia

A 62-year-old man presented with a right-sided hemichorea-hemiballismus secondary to underlying non-ketotic hyperglycaemia. This condition is recognised to have a unique finding of unilateral basal ganglia lesion, which is hyperdense on CT and hyperintense on T1-weighted MRI. The clinical course of this condition is benign and has a good prognosis with early correction of the hyperglycaemia.