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Lee D, Kwon YN, Shon SH, Lee JH, Ahn TB. Glycemic and vascular choreoballism as main causes of secondary choreoballism involving the putamen. Parkinsonism Relat Disord 2016; 30:29-35. [PMID: 27353422 DOI: 10.1016/j.parkreldis.2016.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/23/2016] [Accepted: 06/19/2016] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Dokyung Lee
- Department of Neurology, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Young Nam Kwon
- Department of Neurology, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Hyun Shon
- Department of Neurology, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ju Hie Lee
- Department of Pathology, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Tae-Beom Ahn
- Department of Neurology, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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Li JY, Chen R. Increased intracortical inhibition in hyperglycemic hemichorea-hemiballism. Mov Disord 2014; 30:198-205. [DOI: 10.1002/mds.25940] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 04/22/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jie-Yuan Li
- Division of Neurology; Kaohsiung Veterans General Hospital; Taiwan R.O.C
- Faculty of Medicine; School of Medicine; National Yang-Ming University; Taiwan R.O.C
- Department of Nursing; Yuh-Ing Junior College of Health Care & Management; Taiwan R.O.C
| | - Robert Chen
- Division of Neurology, Department of Medicine and Toronto Western Research Institute; University of Toronto; Toronto Ontario Canada
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Valenti R, Ceccarelli E, Cerase A, Ruvio M, Capodarca C, Martini G, Nuti R. Choreoathetosis associated with non-chetotic hyperglycemia. Acta Diabetol 2012; 49:233-7. [PMID: 20614224 DOI: 10.1007/s00592-010-0185-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
Abstract
Choreoathetosis is a rare neurologic complication of the diabetic disease. The purpose of this case report is to increase the knowledge of such occurrence by describing the case of an elderly woman who was admitted to our institution for an over 20-day history of choreic movement in the left side of the body. She had a 6-year history of type 2 diabetes mellitus with a poor metabolic control including a glycosylated hemoglobin of 13%. Unenhanced computed tomography of the brain was negative. At magnetic resonance imaging, the right putamen showed high signal intensity on T1-weighted images and an area of high signal intensity on T2-weighted images, diffusion-weighted images and apparent diffusion coefficient maps. During the hospitalization, an adequate diet therapy was performed, and insulin therapy was gradually adjusted using regular insulin at main meals associated with basal insulin (glargine) "bed time". This resulted in progressive normalization of blood glucose values and an improvement of dyskinesia. There is a deep correlation between non-chetotic hyperglycemia and neurologic lesions leading to choreoathetosis. The etiopathogenesis seems multifactorial, and include hyperosmolar damage on cortical cells, alteration in GABA neurotransmission and in cerebral vascular self-regulation mechanism. Notably, in DM type 2 choreoathetosis may be related to both vascular and neuro-metabolic alterations in the basal nucleus due to inadequate glycemic control continuing in the time. This rare complication of DM type 2 is a pathological entity to be considered benign, since it is generally transient and reversible with the attainment of an adequate metabolic compensation.
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Affiliation(s)
- Roberto Valenti
- Department of Internal Medicine and Metabolic Disease, University of Siena, Siena, Italy.
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Stereotypies as a manifestation of acute hyperglycemia without ketosis. J Neurol Sci 2011; 315:176-7. [PMID: 22123156 DOI: 10.1016/j.jns.2011.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 11/04/2011] [Indexed: 11/22/2022]
Abstract
Acute hyperglycemia without ketosis is recognized to induce movement disorders characterized by hemichorea, hemiballismus, or hemidystonia. A video-case of hyperkinetic movement disorder resembling stereotypies in the context of uncompensated hyperglycemia without ketosis is presented, expanding the clinical phenotype of this disorder.
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Ondo WG. Hyperglycemic nonketotic states and other metabolic imbalances. HANDBOOK OF CLINICAL NEUROLOGY 2011; 100:287-91. [PMID: 21496588 DOI: 10.1016/b978-0-444-52014-2.00021-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemichorea and generalized chorea are well-recognized syndromes associated with nonketotic hyperglycemia. This condition usually occurs in older age, affects females more than men, and often heralds a new diagnosis of diabetes, usually type 2. It may resolve over days with treatment of the underlying hyperglycemia or persist for years. Magnetic resonance imaging is very characteristic, and shows T1 hyperdensity in the striatum. The underlying pathophysiology is not clear, but recent evidence suggests that the imaging may represent zinc, as opposed to calcium. Tetrabenazine has worked well when symptomatic treatment is required. Other rare causes of metabolic choreas include hypoparathyroid abnormalities, hypoglycemia, and hypernatremia.
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Sung YH, Park KH, Lee YB, Park HM, Shin DJ. Chorea in the both lower limbs associated with nonketotic hyperglycemia. J Mov Disord 2009; 2:98-100. [PMID: 24868369 PMCID: PMC4027719 DOI: 10.14802/jmd.09027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 10/14/2009] [Accepted: 10/30/2009] [Indexed: 11/27/2022] Open
Abstract
Hemichorea-hemiballism (HC-HB) is a complication of non-ketotic hyperglycemia (NKH); in NKH patients, the frequency of occurrence of HC-HB is greater than that of bilateral chorea. We report the case of a hyperglycemic patient who showed chorea in both the lower limbs. Magnetic resonance imaging (MRI) of the brain revealed high signal intensity on T1-weighted images of the bilateral dorsolateral putamen. The abnormal involuntary movements disappeared after oral administration of haloperidol. Our case report that chorea associated with NKH is correlated with the topography of the basal ganglia.
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Affiliation(s)
- Young-Hee Sung
- Department of Neurology, Gachon University of Medicine and Science, Incheon, Korea
| | - Ki-Hyung Park
- Department of Neurology, Gachon University of Medicine and Science, Incheon, Korea
| | - Yeung-Bae Lee
- Department of Neurology, Gachon University of Medicine and Science, Incheon, Korea
| | - Hyeon-Mi Park
- Department of Neurology, Gachon University of Medicine and Science, Incheon, Korea
| | - Dong-Jin Shin
- Department of Neurology, Gachon University of Medicine and Science, Incheon, Korea
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Hemichorea-hemiballismus associated with nonketotic hyperglycemia: a possible role of inflammation. J Neurol Sci 2009; 284:198-202. [PMID: 19428031 DOI: 10.1016/j.jns.2009.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Revised: 03/18/2009] [Accepted: 04/02/2009] [Indexed: 11/20/2022]
Abstract
Three cases of hemichorea-hemiballismus (HC-HB) associated with nonketotic hyperglycemia were reported. Of them two patients presented as HC-HB and the remaining one as generalized chorea-ballismus (CB). Brain MRI showed characteristic T1-weighted high-intensity lesions in the contralateral or bilateral striatum without edema or mass effect. They all had a prior history of respiratory or urinary infection. Cerebrospinal fluid test in two patients showed an elevation of protein concentration with normal cell and an increased IgG content and elevated IgG index or 24 h IgG intrathecal synthesis rate. These results suggested that inflammation within the central nervous system may participate in the pathogenesis of chorea and ballismus induced by NKH.
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Di Lazzaro V, Dileone M, Pilato F, Contarino MF, Musumeci G, Bentivoglio AR, Tonali PA, Rothwell JC. Repetitive transcranial magnetic stimulation of the motor cortex for hemichorea. J Neurol Neurosurg Psychiatry 2006; 77:1095-7. [PMID: 16914763 PMCID: PMC2077745 DOI: 10.1136/jnnp.2005.082875] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ohmori H, Hirashima K, Ishihara D, Maeda Y, Hirano T, Uyama E, Uchino M. Two cases of hemiballism-hemichorea with T1-weighted MR image hyperintensities. Intern Med 2005; 44:1280-5. [PMID: 16415550 DOI: 10.2169/internalmedicine.44.1280] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Hiroyuki Ohmori
- Department of Neurology, Graduate School of Medical Science, Kumamoto University, and the Department of Neurology, Yamaga Chuo Hospital, Japan
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Lee EJ, Choi JY, Lee SH, Song SY, Lee YS. Hemichorea-hemiballism in primary diabetic patients: MR correlation. J Comput Assist Tomogr 2002; 26:905-11. [PMID: 12488734 DOI: 10.1097/00004728-200211000-00009] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this work was to describe the characteristic imaging findings and clinical presentations in patients with hemichorea-hemiballism (HC-HB) associated with nonketotic hyperglycemia (NKH) in primary diabetes mellitus (DM). METHOD The MR findings from six patients with HC-HB associated with NKH in primary DM were evaluated. Their ages ranged from 43 to 81 years. CT was performed on three patients, one of whom underwent a SPECT exam and another who had follow-up MRI. RESULTS A high-signal putaminal lesion was evident on the T1-weighted images in all cases without edema or mass effect. Three of the six cases also showed high-signal intensities in the caudate. Two cases revealed high-signal intensities in the globus pallidus, and the lesions extended to the midbrain in one patient. The T2-weighted and FLAIR images were more variable. One diffusion-weighted image showed increased signal intensity. All three patients who had postcontrast MRI showed no enhancement. Two of the three patients who had CT studies showed high attenuation and the other isodensity. The SPECT study showed decreased perfusion. In all our patients, the chorea resolved within days to weeks after correction of the underlying hyperglycemia. CONCLUSION In patients with HC-HB with NKH in primary DM, T1-weighted MR images showed hyperintense lesions of the putamen or caudate. Early recognition of these imaging characteristics may facilitate the diagnosis of primary DM with hyperglycemia and lead to prompt and appropriate therapy.
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Affiliation(s)
- Eun Ja Lee
- Department of Radiology, College of Medicine, Myongji Hospital, Kwandong University, Koyang City, 697-24 Hwajung-dong, Dukyang-gu, Koyang City 412-270, Korea.
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Oh SH, Lee KY, Im JH, Lee MS. 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. J Neurol Sci 2002; 200:57-62. [PMID: 12127677 DOI: 10.1016/s0022-510x(02)00133-8] [Citation(s) in RCA: 207] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chorea associated with non-ketotic hyperglycemia and high signal intensity lesions on T1-weighted brain magnetic resonance images (C-H-BG) is recognized as a unique syndrome that affects elderly women exclusively. However, its overall clinical features are unclear. MATERIAL AND METHODS The literature describing patients with C-H-BG from 1985 to 2001 was reviewed using MEDLINE. Their clinical features and those of four patients with C-H-BG at this hospital were analyzed. RESULTS This study included 49 patients from the literature and four patients at this hospital. Their mean age at the onset was 71.1 years (range=22-92 years). Women were affected more frequently than men (men/women=17:30). The mean serum glucose level measured after the onset of chorea was 481.5 mg/dl (ranging from 169 to 1264), HbA1c level was 14.4% (ranging from 9.9 to 19.2), and the serum osmolarity was 305.9 mmol/kg (ranging from 291 to 335). Forty-seven patients developed hemichorea. Six patients developed bilateral chorea, and magnetic resonance imaging (MRI) showed bilateral basal ganglia lesions. MRI showed that putamen was involved in all cases (isolated putamen=31 patients, additional basal ganglia lesions=22 patients). None had lesions confined to the caudate nucleus or the globus pallidus. In all, except one, the anterior limb of the internal capsule was spared. Follow-up MRI studies were performed in 22 patients. In most, hemichorea improved along with the disappearance of the lesions. In 39 patients, chorea had ameliorated completely. The remaining 14 cases showed some improvement during the follow-up period. The chorea recurred in seven patients. CONCLUSION C-H-BG is a benign disorder affecting the elderly. It affects men much more frequently than has been reported. The high signal intensity basal ganglia lesion on the T1-weighted brain MRI study was reversible, and correlated with the clinical improvement in chorea.
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Affiliation(s)
- Seung-Hun Oh
- Department of Neurology, Yongdong Severance Hospital, Brain Korea 21 Project for Medicine, Yonsei University College of Medicine, 146-92 Dogok-dong, Kangnam-ku, Seoul, South Korea
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Abstract
The author reviews the applications of transcranial magnetic stimulation (TMS) in a series of movement disorders--namely, Parkinson's disease, corticobasal degeneration, multiple system atrophy, progressive supranuclear palsy, essential tremor, dystonia, Huntington's chorea, myoclonus, the ataxias, Tourette's syndrome, restless legs syndrome, Wilson's disease, Rett syndrome, and stiff-person syndrome. Single- and paired-pulse TMS studies have been done mainly for pathophysiologic purposes. Repetitive TMS has been used largely for therapy. Many TMS abnormalities are seen in the different diseases. They concur to show that motor cortical areas and their projections are the main target of the basal ganglia dysfunction typical of movement disorders. Interpretation has not always been clear, and sometimes there were discrepancies and contradictions. Largely, this may be the result of the extreme heterogeneity of the methods used and of the patients studied. It is premature to give repetitive TMS a role in treatment. Overall, however, TMS gives rise to a new, outstanding enthusiasm in the neurophysiology of movement disorders. There is reason to predict that TMS, with its continuous technical refinement, will prove even more helpful in the near future. Then, research achievements are reasonably expected to spill over into clinical practice.
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Affiliation(s)
- Roberto Cantello
- Department of Medical Sciences, Section of Neurology, School of Medicine, Amedeo Avogadro University, Novara, Italy.
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Ifergane G, Masalha R, Herishanu YO. Transient hemichorea/hemiballismus associated with new onset hyperglycemia. Can J Neurol Sci 2001; 28:365-8. [PMID: 11766783 DOI: 10.1017/s0317167100001608] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe three patients suffering from transient hemichorea/hemiballismus associated with hyperglycemia, review previous reports and propose a possible pathophysiological explanation for this phenomenon. RESULTS Our original cases and previously reported ones reveal a uniform syndrome: mostly female patients (F/M ratio of 11/2), 50-80 years old, usually with no previous history of diabetes mellitus (9/13), develop choreic or ballistic movements on one side of the body over a period of hours. Serum glucose levels are elevated. In most of the patients, a lowering of the blood sugar level reverses the movement disorder within 24-48 hours. CONCLUSIONS We believe that the combination of a recent or old striatal lesion (causing increased inhibition of the subthalamic nucleus) and hyperglycemia (causing decreased GABAergic inhibition of the thalamus) may be responsible for the appearance of this unilateral hyperkinetic movement disorder. Undiagnosed diabetes mellitus should always be suspected in patients who develop hemiballistic or hemichoreic movements. When hyperglycemia is detected and corrected, the movement disorder usually resolves within two days and may not require symptomatic therapy with dopamine receptor antagonists.
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Affiliation(s)
- G Ifergane
- Department of Neurology, Soroka Medical Center, Ben Gurion University, Beer Sheva, Israel
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