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 dystonia in type 1 diabetes: a case report

INTRODUCTION

Diabetic hemichorea-hemiballismus is a rare complication of type 2 diabetes. Here, we report a case with type 1 diabetes, with hemichorea and bilateral dystonia manifested as hyperglycemia-induced involuntary movement.

CASE PRESENTATION

A 62-year-old Japanese women with body weight loss of 30 kg during the past year developed symptoms of thirst, polydipsia and polyuria. She also presented with hemichorea and bilateral dystonia for 5 days and extremely high plasma glucose (774 mg/dl), hemoglobin A1c (21.2%) and glycated albumin (100%) with ketosis. Based on the presence of glutamic acid decarboxylase antibodies (18,000 U/ml; normal <1.3 U/ml), low daily urinary excretion of C-peptide (7.8 micro), ketosis and human leucocyte antigen typing DR-4, we diagnosed type 1 diabetes mellitus. We treated the patient with a continuous intravenous regular insulin infusion and medication with haloperidol, and dystonia completely disappeared within 3 days.

CONCLUSION

Hyperglycemia-induced involuntary movement is one of the manifestations of dystonia and hemichorea-hemiballism.

Acute onset hemichorea-hemiballism. MRI signal abnormality in a metabolically normal patient. A case report

Abnormal signals involving the basal ganglia on MR images have been reported with new-onset hemichorea-hemiballism, typically in elderly Asian patients. The most common cause is a vascular lesion, but many cases are reported in association with hyperglycemia. We describe one case of acute onset chorea-hemiballism with abnormal MRI signal in the basal ganglia but with no systemic abnormality.

Brain and Upper Extremity PET/CT Findings of Hyperglycemia-Induced Hemiballism-Hemichorea

Hyperglycemia-induced hemiballism-hemichorea is an uncommon movement disorder probably related to vascular insult of the basal ganglia in patients with poorly controlled diabetes. This rare clinical entity has been reported with abnormal brain findings on CT, MR, and F-18 FDG PET. The author presents additional PET/CT features of such an unusual dyskinetic syndrome with increased radiotracer uptake in the left motor cortex and musculature of the right shoulder girdle and upper extremity from hemiballism-hemichorea.

Chorea-Ballism as a Manifestation of Decompensated Type 2 Diabetes Mellitus

Chorea and ballism are movement disorders that result from a variety of conditions. Hyperglycemia is an unusual recognized cause of these movement disorders. We report 3 cases of new-onset chorea-ballism induced by nonketotic hyperglycemia in elderly patients, highlighting that chorea may be the first manifestation of undiagnosed decompensated diabetes mellitus.

Tetrabenazine for hyperglycemic-induced hemichorea-hemiballismus

We reported a 74-year-old woman with new-onset diabetes mellitus who presented with the sudden onset of mild left hemiparesis and marked left hemichorea-hemiballismus. Brain CT scan and MRI showed T1W, T2W, and DWI lesions in the right putamen and caudate, which have been previously reported in cases of hyperglycemic-induced hemichorea-hemiballismus (HIHH). The patient dramatically responded to tetrabenazine within a day. Subsequent dose reductions lead to a reemergence of symptoms. Tetrabenazine improves a variety of hyperkinetic movement disorders but, to our knowledge, its use has never been reported for HIHH.

Radiological and pathological changes in hemiballism-hemichorea with striatal hyperintensity

We report CT and MRI findings in a 50-year-old African-American woman with hemichorea-hemiballism (HCHB) and hyperglycemia with striatal hyperintensity. Histopathologic findings following autopsy are also described, and possible explanations for the MR findings of this unique syndrome are presented.

Two cases of hemiballism-hemichorea with T1-weighted MR image hyperintensities

Two cases of hemiballism-hemichorea have been reported in woman patients with hyperglycemia; this was a feature of striatal hyperintensity on the T1-weighted MRI. In the first case, strict management of diabetes and treatment with pimozide effectively suppressed the movement disorder. The Z-score Imaging System revealed hyperperfusion in the bilateral dentate nuclei, left striatum, and bilateral motor cortices. In the second case, painful hemiballism-hemichorea limb, followed by the upper limb. The severity of HB-HC corresponded to the expansion of the striatal lesion. The mechanism of HB-HC by using statistical cerebral blood flow evaluation has also been discussed.

Hyperglycemia-induced unilateral basal ganglion lesions with and without hemichorea A PET study

Hyperglycemia-induced unilateral basal ganglion lesions occur mostly in Asian patients. A signal abnormality in the basal ganglion region is evident on these patients' neuroimaging. Despite characteristic imaging findings and clinical manifestations, the underlying mechanism is still unclear. To clarify the underlying pathophysiology of unilateral basal ganglion lesions, we examined the [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) findings in 3 patients with hyperglycemia. The PET studies were performed at 3 weeks, 5 weeks, and 7 months after clinical onset. The markedly reduced rates of cerebral glucose metabolism in the corresponding lesions on T1-weighted magnetic resonance images provided direct evidence of regional metabolic failure. We suggest that the metabolic derangements associated with hyperglycemia and vascular insufficiency contribute to regional metabolic failure in patients with poorly controlled diabetes mellitus.

Striatal hyperintensity on T1-weighted magnetic resonance images and high-density signal on CT scans obtained in patients with hyperglycemia and no involuntary movement. Report of two cases

The authors report on two patients in whom an increased signal on T1-weighted magnetic resonance images and a high-density signal on computerized tomography scans of the striatum were demonstrated, both of which were associated with nonketotic hyperglycemia. Involuntary movements, which have been present in all previously reported cases, were not observed in either patient at any time during the entire course of illness. One patient displayed hemiparesis, whereas the other had dementia, gait disturbance, and urinary incontinence. Clinical and radiological abnormalities improved on control of blood glucose levels. Invasive studies, including biopsy procedures, should be avoided on encountering this disease given the good prognosis that results from simple medical treatment.

Hemiballism: revisiting a classic disorder

Hemiballism is a rare movement disorder that presents with unilateral flinging movements of the limbs. In traditional teaching, it has been characterised as almost pathognomonic of a lesion in the subthalamic nucleus (STN). The prognosis was described as grave, with severe disability and death in many cases. However, review of more recent reports shows that the STN is directly involved in only a minority of cases. The prognosis is benign in most cases, with almost all patients responding well to treatment and many having spontaneous remission, although long-term prognosis of cerebrovascular disease may not be so good. There have also been recent insights into the pathophysiology of hemiballism, which have emphasised the importance of altered firing patterns in basal-ganglia structures. Recent studies have pointed to previously unrecognised causes, particularly non-ketotic hyperosmolar hyperglycaemia and complications of HIV infection, that may account for a substantial proportion of cases of hemiballism.

Cerebral injury in association with profound iatrogenic hyperglycemia in a neonate

The adverse effect of hyperglycemia on neurological outcome following cerebral ischemia has been established in both experimental and adult human studies. However, there is a paucity of data to assess this risk in the human infant. This case is the first to describe severe and prolonged iatrogenic hyperglycemia in association with ischemia in an infant who sustained a major cerebral lesion. The topography of the predominant cerebral injury, i.e., bilateral parieto-occipital cortex and subcortical white matter, shown by magnetic resonance imaging was similar to that documented in the hypoglycemic infant, suggesting a similarity in regional cerebral vulnerability to altered glucose metabolism. This case extends recognition of the risk of severe hyperglycemia in association with cerebral ischemia to the newborn and suggests also that the posterior cerebral predilection for injury is similar in both hypoglycemia and hyperglycemia.