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Greco F, Buoso A, Cea L, D’Andrea V, Bernetti C, Beomonte Zobel B, Mallio CA. Magnetic Resonance Imaging in Uremic Encephalopathy: Identifying Key Imaging Patterns and Clinical Correlations. J Clin Med 2024; 13:4092. [PMID: 39064132 PMCID: PMC11278456 DOI: 10.3390/jcm13144092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/07/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Magnetic Resonance Imaging (MRI) is essential in diagnosing neurological conditions, offering detailed insights into brain pathology. Uremic encephalopathy (UE) is a severe neurological disorder resulting from renal failure, characterized by cognitive impairments and brain abnormalities due to the accumulation of uremic toxins (UTs). Despite extensive research on UTs, there is a significant gap in the detailed characterization of MRI findings in UE patients. This study aims to bridge this gap by conducting a comprehensive literature review of cerebral MRI findings in UE. We hypothesize that specific MRI patterns correlate with the severity and clinical manifestations of UE, thereby enhancing diagnostic accuracy and improving patient outcomes. Methods: A literature review was performed using PubMed, Cochrane Library, and Google Scholar. The search terms included "uremic encephalopathy MRI", "uremia and kidney failure MRI", and "toxic and metabolic or acquired encephalopathies MRI". The inclusion criteria were original articles on UE and MRI findings published in English. Results: Common MRI sequences include T1-weighted, T2-weighted, FLAIR, and DWI. Frequent MRI findings in UE are cytotoxic and vasogenic brain edema in regions such as the basal ganglia and periventricular white matter. Patterns like the "lentiform fork sign" and basal ganglia involvement are key indicators of UE. Conclusions: MRI plays a crucial role in diagnosing UE by identifying characteristic brain edema and specific patterns. A comprehensive diagnostic approach, incorporating clinical, laboratory, and imaging data, is essential for accurate diagnosis and management. The study calls for larger well-designed cohorts with long-term follow-up to improve the understanding and treatment of UE.
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Affiliation(s)
- Federico Greco
- Department of Radiology, Cittadella della Salute, Azienda Sanitaria Locale di Lecce, Piazza Filippo Bottazzi, 2, 73100 Lecce, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
| | - Andrea Buoso
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Laura Cea
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Valerio D’Andrea
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Caterina Bernetti
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Bruno Beomonte Zobel
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Carlo Augusto Mallio
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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Yang G, Wang LZ, Zhang R, Zhang XY, Yu Y, Ma HR, He XG. Study on the Correlation between Blood Urea Nitrogen, Creatinine Level, Proteinuria and Parkinson's Disease. Neurol India 2023; 71:1217-1221. [PMID: 38174461 DOI: 10.4103/0028-3886.391388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Introduction Parkinson's disease (PD) is related to renal insufficiency. The purpose of this study was to explore the correlation between PD and blood urea nitrogen, creatinine, and proteinuria. Methods The case-control study method was adopted in this study. In total, 200 patients with PD who were hospitalized in the Department of Neurology of the Second Affiliated Hospital of Anhui Medical University were selected as the PD group, and 110 healthy patients during the same period were selected as the control group. The differences in clinical data and laboratory results between the two groups were compared. Logistic regression analysis, ROC curve, and Spearman correlation analysis were used to determine the correlation between PD and blood urea nitrogen, creatinine, and urine protein. Results The levels of cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL-C), and apolipoprotein B in the PD group were lower than those in the control group. The levels of creatinine, urea nitrogen, and proteinuria in the PD group were higher than those in the control group. Multivariate logistic regression analysis showed that elevated blood urea nitrogen, creatinine, and urine protein levels were risk factors for PD, and elevated LDL-C levels were protective factors for PD. The blood urea nitrogen level of patients with PD was positively correlated with the course of PD, Hoehn-Yahr staging, and UPDRS exercise score (r = 0.309, 0.434, and 0.540, respectively; P < 0.01). Serum creatinine level was positively correlated with the course of PD, Hoehn-Yahr staging, and UPDRS exercise score (r = 0.139, 0.320, and 0.290, respectively; P < 0.01). Conclusion Blood urea nitrogen, creatinine levels, and proteinuria can be regarded as the onset of PD and a biomarker of disease progression.
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Affiliation(s)
- Guang Yang
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan; Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ling Zhi Wang
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Rong Zhang
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Xiao Yu Zhang
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Yue Yu
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Hai Rong Ma
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Xiao Gang He
- Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
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Sina F, Najafi D, Aziz-Ahari A, Shahraki E, Ahimahalle TZ, Namjoo Z, Hassanzadeh S. Uremic encephalopathy: A definite diagnosis by magnetic resonance imaging? Eur J Transl Myol 2022; 32. [PMID: 36036353 PMCID: PMC9580542 DOI: 10.4081/ejtm.2022.10613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/18/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate the magnetic resonance imaging (MRI) findings for the diagnose uremic encephalopathy and describe the usefulness of MRI findings in the ultimate diagnosis of uremic encephalopathy (UE). A total of 20 patients with uremic encephalopathy admitted to the hospital were evaluated in this prospective study. The clinical manifestations, laboratory and MRI imaging findings, demographic information, and clinical outcome were analyzed for each patient. We observed that the 20 prospectively reviewed patients with UE had no involvement of the basal ganglia or the lentiform fork sign (LFS). However, two-thirds of the patients had white matter involvement, and 80% of the subjects had cerebral or cortical atrophy. The arterial blood gas (ABG) analysis revealed that 50% of the patients suffered from metabolic acidosis (n=10). The results of the present study demonstrated that although the observation of Lentiform Fork Sign and Basal Ganglia involvement in MRI of UE patients is a specific finding the absence of which does not rule out UE. Thus, simultaneous examination of clinical manifestation and laboratory test analyses, along with imaging findings, should also be taken into account.
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Jeon SJ, Choi SS, Kim HY, Yu IK. Acute Acquired Metabolic Encephalopathy Based on Diffusion MRI. Korean J Radiol 2021; 22:2034-2051. [PMID: 34564957 PMCID: PMC8628163 DOI: 10.3348/kjr.2019.0303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/02/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022] Open
Abstract
Metabolic encephalopathy is a critical condition that can be challenging to diagnose. Imaging provides early clues to confirm clinical suspicions and plays an important role in the diagnosis, assessment of the response to therapy, and prognosis prediction. Diffusion-weighted imaging is a sensitive technique used to evaluate metabolic encephalopathy at an early stage. Metabolic encephalopathies often involve the deep regions of the gray matter because they have high energy requirements and are susceptible to metabolic disturbances. Understanding the imaging patterns of various metabolic encephalopathies can help narrow the differential diagnosis and improve the prognosis of patients by initiating proper treatment regimen early.
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Affiliation(s)
- Se Jeong Jeon
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - See Sung Choi
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - Ha Yon Kim
- Department of Radiology, Eulji University Hospital, Deajeon, Korea
| | - In Kyu Yu
- Department of Radiology, Eulji University Hospital, Deajeon, Korea.
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Abstract
BACKGROUND Basal ganglia (BG) lesions are rarely reported in patients with uremia and may manifest by movement disorders. However, their exact incidence and pathogenesis have not been extensively studied. This study aimed to determine the frequency, types, risk variables (clinical, laboratory, and imaging), and manifestations of BG lesions with uremia and patients' neurologic outcomes. METHODS This observational study included 70 adults (mean age: 45.87 ± 3.36 years; duration of uremia: 5.5 ± 1.5 years). They underwent extensive evaluations (clinical, laboratory, and neuroimaging) and had prospectively evaluated clinically every 3 months for 2 years. Repeated magnetic resonance imaging (MRI) brains were done to patients with movement disorders and correlated with their neurologic outcomes. RESULTS BG lesions were found in 15 patients (21.4%) and 6 (8.6%) had movement disorders [Parkinsonism (n = 4), choreo-dystonia (n = 1) and dystonia (n = 1)] after the onset of uremia (mean = 10 months). There were no characteristic risk variables that distinguished patients with movement disorders from those without. Five developed movement disorders prior to the period of the study and one was de novo. The majority was females and had diabetes and higher frequencies of abnormal renal dysfunction, metabolic derangements, and white matter hyperintensities in MRIs. Movement disorders persisted in all patients despite the resolution of neuroimaging in three patients. CONCLUSIONS There is no clear threshold for renal failure to result in movement disorders due to BG lesions. The clinical outcome is variables depending on each patient's comorbidities and complications. Persistent neuronal damage (due to uremic toxins/metabolic/nutritional and ischemic/microvascular factors) has been suggested as the cause of poor neurologic outcomes.
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Incident Parkinson's disease in kidney transplantation recipients: a nationwide population-based cohort study in Korea. Sci Rep 2021; 11:10541. [PMID: 34007005 PMCID: PMC8131700 DOI: 10.1038/s41598-021-90130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/19/2021] [Indexed: 11/08/2022] Open
Abstract
This nation-wide population based retrospective cohort study evaluated risk of incident Parkinson’ disease in kidney transplant (KT) recipients in Korea. From Korean National Health Insurance Service database, we identified incident KT recipients aged ≥ 40 years without any history of Parkinson’s disease between 2007 and 2015. We established two control cohorts without a history of Parkinson’ disease: (1) General population (GP) cohort of insured subjects without a history of kidney disease, (2) end-stage renal disease (ESRD) cohort of incident ESRD subjects, with frequency matched for age, sex, and inclusion year. Parkinson’s disease data were obtained from baseline until December 2017. We followed 8372 KT recipients, ESRD patients, and GP for 45,723, 38,357, and 47,476 patient-years, respectively. Their mean age was 51.2 years and 60.1% were men. During follow-up period, 19 KT recipients, 53 ESRD patients, and 15 GP developed Parkinson’ disease. Risk of incident Parkinson’s disease in KT recipients was similar to that in GP (adjusted hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.35 to 2.13, P = 0.75) and significantly lower than that in ESRD patients (adjusted HR 0.31, 95% CI 0.18 to 0.52, P < 0.001). Older age was the strongest predictor for incident Parkinson’s disease in KT recipients.
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Meléndez-Flores JD, Estrada-Bellmann I. Linking chronic kidney disease and Parkinson's disease: a literature review. Metab Brain Dis 2021; 36:1-12. [PMID: 32990929 DOI: 10.1007/s11011-020-00623-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
Chronic kidney disease (CKD) has been typically implicated in cardiovascular risk, considering the function the kidney has related to blood pressure, vitamin D, red blood cell metabolism, and electrolyte and acid-base regulation. However, neurological consequences are also attributed to this disease. Among these, recent large epidemiological studies have demonstrated an increased risk for Parkinson's disease (PD) in patients with CKD. Multiple studies have evaluated individually the association of blood pressure, vitamin D, and red blood cell dysmetabolism with PD, however, no study has reviewed the potential mechanisms related to these components in context of CKD and PD. In this review, we explored the association of CKD and PD and linked the components of the former to propose potential pathways explaining a future increased risk for PD, where renin-angiotensin system, oxidative stress, and inflammation have a main role. Potential preventive and therapeutic interventions based on these associations are also explored. More preclinical studies are needed to confirm the potential link of CKD conditions and future PD risk, whereas more interventional studies targeting this association are warranted to confirm their potential benefit in PD.
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Affiliation(s)
- Jesús D Meléndez-Flores
- Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, 64700, Monterrey, NL, Mexico
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Ingrid Estrada-Bellmann
- Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, 64700, Monterrey, NL, Mexico.
- Movement Disorders Clinic, Neurology Division, Internal Medicine Department, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
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Metin KM, Ataç C, Şahin BE, Yoldaş TK. The Syndrome of Acute Bilateral Basal Ganglia Lesions in a Patient with Diabetes Mellitus and Uremia. Neurol India 2019; 67:1163-1165. [PMID: 31512672 DOI: 10.4103/0028-3886.266236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Kubra Mehel Metin
- Clinic of Neurology, Ankara Education and Research Hospital, Ankara, Turkey
| | - Ceyla Ataç
- Clinic of Neurology, Ankara Education and Research Hospital, Ankara, Turkey
| | - Burç Esra Şahin
- Clinic of Neurology, Ahi Evran University Education and Research Hospital, Kırşehir, Turkey
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Nam GE, Kim NH, Han K, Choi KM, Chung HS, Kim JW, Han B, Cho SJ, Jung SJ, Yu JH, Park YG, Kim SM. Chronic renal dysfunction, proteinuria, and risk of Parkinson's disease in the elderly. Mov Disord 2019; 34:1184-1191. [PMID: 31021467 DOI: 10.1002/mds.27704] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/09/2019] [Accepted: 04/04/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The roles of chronic kidney disease and proteinuria in the development of Parkinson's disease have not been widely studied. The objective of this study was to examine the associations of chronic renal dysfunction and proteinuria with the risk of PD in older adults using cohort data of the whole South Korean population. METHODS We included 3,580,435 individuals aged ≥65 years who had undergone health checkups provided by the National Health Insurance Service of South Korea between 2009 and 2012 and were followed until 2015. Multivariable Cox proportional hazards regression models were performed. RESULTS During a mean follow-up of 5.2 ± 1.3 years, 30,813 individuals (0.86% of the total population) developed PD. Lower estimated glomerular filtration rate and a higher degree of proteinuria on a dipstick test were associated with higher incidence probability of PD (log-rank P < 0.001). In Cox regression models, chronic renal dysfunction graded by estimated glomerular filtration rate (mL/min/1.73 m2 ) was associated with increased risk of PD after adjusting for potential confounding variables; hazard ratio (95% confidence interval) was 1.13 (1.10-1.17) for estimated glomerular filtration rate 60-90, 1.36 (1.31-1.42) for estimated glomerular filtration rate 30-60, and 1.47 (1.32-1.63) for estimated glomerular filtration rate <30 (P for trend <0.001). Proteinuria ≥1+ was also associated with increased risk of PD development (hazard ratio, 1.12; 95% confidence interval, 1.06-1.18). Coexistence of chronic kidney disease and proteinuria showed an increased hazard ratio of 1.33 (95% confidence interval, 1.23-1.45) for PD occurrence. CONCLUSIONS Our findings suggest that chronic renal dysfunction and dipstick-positive proteinuria may be independent risk factors for the development of PD in older adults. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ga Eun Nam
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Nan Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hye Soo Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byoungduck Han
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea.,Department of Family Medicine, Sahmyook Medical Center, Seoul, Republic of Korea
| | - Sung Jung Cho
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea.,Department of Family Medicine, Sahmyook Medical Center, Seoul, Republic of Korea
| | - Seung Jin Jung
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea.,Department of Family Medicine, Sahmyook Medical Center, Seoul, Republic of Korea
| | - Ji Hee Yu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong Gyu Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seon Mee Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Hamed SA. Neurologic conditions and disorders of uremic syndrome of chronic kidney disease: presentations, causes, and treatment strategies. Expert Rev Clin Pharmacol 2019; 12:61-90. [PMID: 30501441 DOI: 10.1080/17512433.2019.1555468] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sherifa A. Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
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Gong WY, Li SS, Yu ZC, Wu HW, Yin LH, Mei LF, Liu FN. Syndrome of uremic encephalopathy and bilateral basal ganglia lesions in non-diabetic hemodialysis patient: a case report. BMC Nephrol 2018; 19:370. [PMID: 30567505 PMCID: PMC6299987 DOI: 10.1186/s12882-018-1174-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uremic encephalopathy (UE), a toxic metabolic encephalopathy, is an uncommon complication resulting from endogenous uremic toxins in patients with severe renal failure. UE syndrome can range from mild inattention to coma. The imaging findings of UE include cortical or subcortical involvement, basal ganglia involvement and white matter involvement. The basal ganglia type is uncommon, although previous cases have reported that Asian patients with diabetes mellitus (DM) are usually affected. CASE PRESENTATION A 32 year-old woman with a history of non-diabetic hemodialysis for 3 years suffered from severe involuntary movement, and brain magnetic resonance imaging showed symmetrical T2-weighted imaging (T2WI) and T2/fluid-attenuated inversion recovery (T2FLAIR) hyperintense nonhemorrhagic lesions in the bilateral basal ganglia. She was diagnosed with UE as syndrome of bilateral basal ganglia lesions, due to a combined effect of uremic toxins and hyperthyroidism. After treatment with high frequency and high flux dialysis, hyperbaric oxygen therapy and declining parathyroid hormone, the patient achieved complete remission with normal body movement and was discharged. CONCLUSION UE with basal ganglia involvement is uncommon, although generally seen in Asian patients with DM. Our case reported a hemodialysis patient that had non-diabetic UE with typical bilateral basal ganglia lesions, presenting with involuntary movement.
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Affiliation(s)
- Wen-Yu Gong
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Shan-Shan Li
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Zong-Chao Yu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Hong-Wei Wu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Liang-Hong Yin
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China
| | - Li-Fan Mei
- Division of Nephrology, Department of medicine, Zhongshan Boai Hospital, Zhongshan, 528400, Guangdong, China
| | - Fan-Na Liu
- Division of Nephrology, Department of medicine, the First Affiliated Hospital, Jinan University, Guangzhou, 510630, Guangdong, China.
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Mehta S, Kumar A, Takkar A, Goyal MK, Lal V. An unusual cause of reversible parkinsonism. Ann Indian Acad Neurol 2017; 20:82-83. [PMID: 28298854 PMCID: PMC5341280 DOI: 10.4103/0972-2327.194315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sahil Mehta
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amith Kumar
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Takkar
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar Goyal
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Lal
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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MRI Findings of Syndrome of Acute Bilateral Symmetrical Basal Ganglia Lesions in Diabetic Uremia: A Case Report and Literature Review. Case Rep Radiol 2016; 2016:2407219. [PMID: 27493824 PMCID: PMC4967458 DOI: 10.1155/2016/2407219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/22/2016] [Indexed: 11/24/2022] Open
Abstract
The syndrome of acute bilateral basal ganglia lesions is an uncommon clinical occurrence exhibiting acute onset of movement abnormalities, which can be seen almost exclusively among patients with chronic renal failure, especially in the setting of concurrent diabetes mellitus. Symmetrical lesions located in basal ganglia demonstrated in MRI are typical manifestation of this syndrome. Our study includes routine MRI examination, MRS, 3D-ASL, and SWI findings, which have been rarely reported and will contribute to diagnosing more cases about this syndrome.
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Park JW, Kim SU, Choi JY, Jung JM, Kwon DY, Park MH. Reversible parkinsonism with lentiform fork sign as an initial and dominant manifestation of uremic encephalopathy. J Neurol Sci 2015; 357:343-4. [DOI: 10.1016/j.jns.2015.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
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15
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Abstract
Parkinsonism associated with basal ganglia pathology represents a rare complication in uremia patients, characterized by acute hyperkinetic or hypokinetic extrapyramidal movement disorders. We herein present brain SPECT and MR findings of uremic patients with end-stage renal failure exhibiting parkinsonian symptoms. The bilateral basal ganglia exhibited decreased uptake on SPECT, and abnormal signals on MR, suggesting pathology.
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Sutter R, Kaplan PW. What to see when you are looking at confusion: a review of the neuroimaging of acute encephalopathy. J Neurol Neurosurg Psychiatry 2015; 86:446-59. [PMID: 25091365 DOI: 10.1136/jnnp-2014-308216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Acute encephalopathy is a clinical conundrum in neurocritical care facing physicians with diagnostic and therapeutic challenges. Encephalopathy arises from several concurrent causes, and delayed diagnosis adds to its grim prognosis. Diagnosis is reached by melding clinical, neurophysiological and biochemical features with various neuroimaging studies. We aimed to compile the pathophysiology of acute encephalopathies in adults, and the contribution of cerebral CT, MRI, MR spectroscopy (MRS), positron emission tomography (PET) and single-photon emission CT (SPECT) to early diagnosis, treatment and prognostication. Reports from 1990 to 2013 were identified. Therefore, reference lists were searched to identify additional publications. Encephalopathy syndromes best studied by neuroimaging emerge from hypoxic-ischaemic injury, sepsis, metabolic derangements, autoimmune diseases, infections and rapidly evolving dementias. Typical and pathognomonic neuroimaging patterns are presented. Cerebral imaging constitutes an important component of diagnosis, management and prognosis of acute encephalopathy. Its respective contribution is dominated by rapid exclusion of acute cerebral lesions and further varies greatly depending on the underlying aetiology and the range of possible differential diagnoses. CT has been well studied, but is largely insensitive, while MRI appears to be the most helpful in the evaluation of encephalopathies. MRS may provide supplementary biochemical information and determines spectral changes in the affected brain tissue. The less frequently used PET and SPECT may delineate areas of high or low metabolic activity or cerebral blood flow. However, publications of MRS, PET and SPECT are limited only providing anecdotal evidence of their usefulness and sensitivity.
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Affiliation(s)
- Raoul Sutter
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA Clinic of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Kim YJ, Kim SJ, Kim J, Kim MJ, Kim KJ, Yoon H, Kim SR, Chung SJ. Chorea due to diabetic hyperglycemia and uremia: distinct clinical and imaging features. Mov Disord 2015; 30:419-22. [PMID: 25649292 DOI: 10.1002/mds.26148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/15/2014] [Accepted: 12/21/2014] [Indexed: 11/06/2022] Open
Abstract
This study was undertaken to describe the clinical and imaging characteristics of patients with chorea associated with nonketotic hyperglycemia (C-NKH) in comparison with patients with chorea associated with uremia (C-URE). We retrospectively analyzed the clinical data of consecutive 10 C-NKH and five C-URE patients who were treated between January 1, 2001 and January 31, 2013. Women were more frequently affected by C-NKH (70% vs. 30%) and C-URE (80% vs. 20%) compared with men. The C-NKH patients demonstrated T1-hyperintense and inhomogeneous lesions in the basal ganglia, whereas C-URE patients demonstrated T2-hyperintense and homogeneous lesions in the basal ganglia. The mean time for chorea resolution after treatment was significantly shorter in C-NKH patients than in C-URE patients (4.4 ± 2.6 d vs. 73.8 ± 14.2 d, respectively; P = 0.005). The clinical and imaging features are remarkably different between C-NKH and C-URE patients, suggesting distinct pathogenic mechanisms.
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Affiliation(s)
- Young Jin Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Park JH, Kim HJ, Kim SM. Acute Chorea with Bilateral Basal Ganglia Lesions in Diabetic Uremia. Can J Neurol Sci 2014; 34:248-50. [PMID: 17598608 DOI: 10.1017/s0317167100006144] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Uremia is a syndrome of clinical and metabolic abnormalities, which develops in parallel with the deterioration of renal function. Uremic encephalopathy is one of many manifestations of acute or chronic renal failure. It is usually applied to patients with cortical involvement, such as confusion, seizure, tremor, myoclonus, or asterixis. Some cases of acute extrapyramidal movement disorders associated with bilateral basal ganglia lesions, especially parkinsonism have been reported in uremic patients. Here, we report a diabetic uremic patient who developed acute chorea associated with bilateral basal ganglia lesions.
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Mahajan PS, El Esnawi MA, Hussein SA, Al Maslamani NJ. Rare case of reversible acute symmetrical lesions of the bilateral Basal Ganglia associated with diabetic nephropathy and chronic renal failure. J Clin Imaging Sci 2014; 4:29. [PMID: 24991480 PMCID: PMC4078418 DOI: 10.4103/2156-7514.133264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 04/21/2014] [Indexed: 11/04/2022] Open
Abstract
Reversible acute symmetrical basal ganglial lesion on magnetic resonance imaging and/or computed tomography in cases of diabetic nephropathy and chronic renal failure exhibiting acute onset of movement abnormalities like chorea is a very rare entity. It has characteristic clinical and imaging features. Only 29 cases are described in the literature, including the current one. These cases are predominantly Asian patients from the Far East and only one Asian Indian patient has been described. We report the second Asian Indian case of this condition and describe its various clinical and imaging features. Our aim is to educate the clinicians and radiologists about this condition, so that more such cases can be detected.
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Affiliation(s)
- Parag Suresh Mahajan
- Department of Radiology, Al-Khor Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Sheik Akbar Hussein
- Department of Radiology, Al-Khor Hospital, Hamad Medical Corporation, Doha, Qatar
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Abstract
Acute encephalopathies arise as a result of various contributions from infections or toxic, metabolic, and/or structural cerebral derangements. With the variety of clinical presentations, neurologic examination, electroencephalography (EEG), and imaging may not identify specific etiologies, but in combination, they can offer guidance regarding underlying causes. Among several different neuroimaging techniques, cerebral computed tomography and brain magnetic resonance imaging are most frequently used for diagnosis, treatment monitoring, and prognostication in acute brain dysfunction. This review compiles the most common and typical features of head computed tomography and magnetic resonance imaging and presents the clinical and EEG associations in adult patients with different types of acute encephalopathy.
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Wang IK, Lin CL, Wu YY, Chou CY, Lin SY, Liu JH, Yen TH, Huang CC, Sung FC. Increased risk of Parkinson's disease in patients with end-stage renal disease: a retrospective cohort study. Neuroepidemiology 2014; 42:204-210. [PMID: 24751820 DOI: 10.1159/000358921] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/20/2014] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Studies on dyskinesia and Parkinson's syndrome associated with chronic kidney disease or end-stage renal disease (ESRD) have been mainly limited to case reports or case series studies. This population-based study investigated the risk of Parkinson's disease in patients with ESRD. METHODS From a universal insurance claims database of Taiwan, we established a cohort of 8,325 adults with newly diagnosed ESRD from 1997 to 2010 without a history of Parkinson's disease. A control cohort of 33,382 insured subjects without a history of kidney disease or Parkinson's disease was also selected, with frequency matched for age, sex and index date of the patients with ESRD. Both cohorts were followed up until the end of 2010. RESULTS The Parkinson's disease incidence was 1.55-fold higher in the cohort with ESRD than in the comparison cohort (48.8 vs. 31.7 per 10,000 person-years) with an adjusted hazard ratio of 1.73 (95% confidence interval, 1.39-2.15). Sex-specific and age-specific analysis showed a higher relative risk for women and younger patients with ESRD compared to the control cohort. CONCLUSIONS ESRD is significantly associated with an increased risk of Parkinson's disease. Close surveillance for Parkinson's disease should be considered for patients with ESRD.
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Affiliation(s)
- I-Kuan Wang
- Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan
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Acar NP, Arsava EM, Gocmen R, Dericioglu N, Topcuoglu MA. Diabetic uremic syndrome studied with cerebral MR spectroscopy and CT perfusion. Metab Brain Dis 2013; 28:711-5. [PMID: 23959792 DOI: 10.1007/s11011-013-9427-x] [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: 05/25/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
Abstract
Diabetic uremic syndrome (DUS) is an increasingly reported acute neurometabolic cerebral disease with characteristic clinical and imaging features. Clinical spectrum includes a wide range of movement disorders such as acute parkinsonism. Imaging studies show reversible (with hemodialysis) bilateral lesions in the lenticular nuclei. DUS pathophysiology has not been entirely clarified yet. Our case study shows certainly that LN lesions are characterized with increased lactate peak with MR spectroscopy and decreased perfusion in computerized tomography perfusion along with increased diffusion with apparent diffusion coefficient (ADC) mapping in the subacute phase of the syndrome. Abnormalities were almost normalized quickly after metabolic control by hemodialysis. Together with reports indicating that a deficit of glucose use exacerbated with acute increase of uremic toxins in bilateral LN, observed changes (lactate peak and hypoperfusion) led us to state that a primary metabolic depression may cause this syndrome. Metabolic depression is probably due to uncompensated uremic toxin accumulation related mitochondrial supression and/or dysfunction. This definition fits well to the other elements of DUS such as ADC evolution and marked lesion regression. Our single case study is not supportive of other previously credited mechanisms such as microvascular dysfunction related focal ischemia or hypoperfusion, prolonged uremic toxin related histotoxic hypoxia, central pontine myelinolysis-like demyelination and posterior leukoencephalopathy spectrum disorder related vasogenic edema.
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Kuppachi S, Lwin L, Yoo J, Suneja M. Bilateral basal ganglia lesions in end-stage kidney disease presenting as acute chorea. Clin Kidney J 2013; 6:450-1. [PMID: 27293580 PMCID: PMC4898345 DOI: 10.1093/ckj/sft073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sarat Kuppachi
- Department of Medicine, Division of Nephrology and Hypertension , University of Iowa Hospital and Clinics , IA , USA
| | - Lin Lwin
- Department of Medicine, Division of Nephrology and Hypertension , Montefiore Medical Center , NY, USA
| | - Jinil Yoo
- Department of Medicine, Division of Nephrology and Hypertension , Montefiore Medical Center , NY, USA
| | - Manish Suneja
- Department of Medicine, Division of Nephrology and Hypertension , University of Iowa Hospital and Clinics , IA , USA
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MRI and CT appearances in metabolic encephalopathies due to systemic diseases in adults. Clin Radiol 2013; 68:545-54. [DOI: 10.1016/j.crad.2012.05.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 05/13/2012] [Accepted: 05/22/2012] [Indexed: 11/17/2022]
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Nishimura Y, Shibata K, Funaki T, Ito H, Ito E, Otsuka K. [A case of subacute parkinsonism presenting as bilateral basal ganglia legions by MRI in diabetic uremic syndrome]. Rinsho Shinkeigaku 2013; 53:217-23. [PMID: 23524602 DOI: 10.5692/clinicalneurol.53.217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 60-year-old male was admitted because he had developed tremulous movement in both upper and lower limbs and gait disturbance over the course of 3 months. He had been on continuous ambulatory peritoneal dialysis almost 1 year earlier due to end-stage diabetic nephropathy. A neurological examination revealed a mild disturbance of his consciousness, asterixis in the upper limbs, bilateral extensor plantar responses and parkinsonism, which were characterized by bradykinesia, akinesia, rigidity, and bilaterally tremors at rest. Cranial magnetic resonance imaging (MRI) revealed swollen bilateral basal ganglia legions, which appeared hyperintense on T2-weighted images. The patient was treated for metabolic acidosis and continued hemodialysis three times a week; however, the parkinsonism remained 1 year later. Follow-up MRI revealed decreased swelling of the basal ganglia, and the pattern of diffusion-weighted images and the apparent diffusion coefficient (ADC) map indicated vasogenic and cytotoxic edema in bilateral globus pallidus. The case was diagnosed as encephalopathy due to diabetic uremic syndrome, initially characterized by Wang et al. (2003). Only 17 cases with parkinsonism have been reported. Diabetic uremic syndrome is characterized by acute or subacute onset consciousness disturbance and movement disorders such as parkinsonism, chorea and the other extrapyramidal signs to various degrees related to bilateral lesions of the basal ganglia.
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Affiliation(s)
- Yoshiko Nishimura
- Tokyo Women's Medical University Medical Center East, Department of Medicine
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Nzwalo H, Sá F, Capela C, Ferreira F, Basílio C. Reversible acute parkinsonism and bilateral Basal Ganglia lesions in a diabetic uremic patient. Case Rep Neurol 2012. [PMID: 23185167 PMCID: PMC3506043 DOI: 10.1159/000345031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The syndrome of bilateral basal ganglia lesions in diabetic uremic patients is a rare disorder mostly reported in Asians. There are few reports of the syndrome in Caucasians. It manifests as an acute hyperkinetic or hypokinetic extrapyramidal disorder in association with uniform neuroimaging findings of bilateral symmetrical basal ganglia changes in diabetics undergoing hemodialysis. Its pathophysiology remains largely unknown. Thus, we report a typical case of the syndrome in a Caucasian patient who developed an acute and reversible akinetic rigid parkinsonism secondary to bilateral basal ganglia lesions.
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Kang E, Jeon SJ, Choi SS. Uremic encephalopathy with atypical magnetic resonance features on diffusion-weighted images. Korean J Radiol 2012; 13:808-11. [PMID: 23118581 PMCID: PMC3484303 DOI: 10.3348/kjr.2012.13.6.808] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 12/15/2011] [Indexed: 12/03/2022] Open
Abstract
Uremic encephalopathy is a well-known disease with typical MR findings including bilateral vasogenic or cytotoxic edema at the cerebral cortex or basal ganglia. Involvement of the basal ganglia has been very rarely reported, typically occurring in uremic-diabetic patients. We recently treated a patient who had non-diabetic uremic encephalopathy with an atypical lesion distribution involving the supratentorial white matter, without cortical or basal ganglia involvement. To the best of our knowledge, this is only the second reported case of non-diabetic uremic encephalopathy with atypical MR findings.
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Affiliation(s)
- Eugene Kang
- Department of Radiology, Wonkwang University School of Medicine & Hospital, Iksan 570-711, Korea
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Abstract
AIMS Movement disorders are one of the central nervous system complications in uremic patients. Asterixis, multifocal myoclonus, and restless leg syndrome are well-documented in this category. Acute parkinsonism, however, is only reported in rare series with a small number of cases. In this study, we investigated the risk for parkinsonism during a 3-year follow-up period after a diagnosis of uremia. METHODS The Longitudinal Health Insurance Database in Taiwan was utilised. We identified a total of 2862 patients who had visited ambulatory care centers with a diagnosis of chronic renal failure between 1999 and 2001 as the study cohort. We further randomly selected 14,310 enrollees matched with the study cohort in terms of gender, age, and year of their index visit for comparison. Each patient was individually tracked for 3 years to identify the occurrence of parkinsonism. Stratified Cox proportional hazard regressions (stratified by age and gender) were performed for analyses. RESULTS We found the annual incidence rates of parkinsonism to be 1.2% and 0.6% in the uremic and non-uremic groups, respectively. Furthermore, uremic patients were more vulnerable to developing parkinsonism with a 1.81-fold higher risk [95%CI = (1.21-2.71)] than the non-uremic group after adjusting for diabetes mellitus, which did not augment the risk. CONCLUSIONS The importance of raising awareness regarding the early symptoms of parkinsonism among patients with uremia is tied to its early identification, with timely aggressive dialysis being able to apply to slow the progression of the disease and its symptoms. Further study is warranted to elucidate the pathophysiology of uremic parkinsonism.
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Affiliation(s)
- H-L Lin
- Department of Neurology, General Cathay Hospital, Sijhih Branch, Taipei, Taiwan
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Movement disorders in patients with diabetes mellitus. J Neurol Sci 2011; 314:5-11. [PMID: 22133478 DOI: 10.1016/j.jns.2011.10.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 10/27/2011] [Accepted: 10/28/2011] [Indexed: 11/20/2022]
Abstract
Movement disorders are not infrequent in patients with diabetes mellitus. These may occur on the basis of both central and peripheral nervous system dysfunction and can be secondary to severe hyperglycemia, complications of diabetes or its treatment and less often to diseases in which both diabetes and a movement disorder are primary manifestations of the same underlying disease. We present a typical case of a severe movement disorder complicating diabetes as a springboard to review the spectrum of disorders associated with this condition.
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Wali GM, Khanpet MS, Mali RV. Acute movement disorder with bilateral basal ganglia lesions in diabetic uremia. Ann Indian Acad Neurol 2011; 14:211-3. [PMID: 22028539 PMCID: PMC3200049 DOI: 10.4103/0972-2327.85899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 04/27/2010] [Accepted: 08/21/2010] [Indexed: 11/08/2022] Open
Abstract
Acute movement disorder associated with symmetrical basal ganglia lesions occurring in the background of diabetic end stage renal disease is a recently described condition. It has distinct clinico-radiological features and is commonly described in Asian patients. We report the first Indian case report of this potentially reversible condition and discuss its various clinico-radiological aspects.
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Generalized chorea in the syndrome of acute bilateral basal ganglia lesions in patients with diabetic uremia. J Clin Neurosci 2011; 18:1266-8. [DOI: 10.1016/j.jocn.2011.01.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 01/17/2011] [Accepted: 01/26/2011] [Indexed: 11/17/2022]
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Juryńczyk M, Rozniecki J, Zaleski K, Selmaj K. Hypoglycemia as a trigger for the syndrome of acute bilateral basal ganglia lesions in uremia. J Neurol Sci 2010; 297:74-5. [PMID: 20709331 DOI: 10.1016/j.jns.2010.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
Abstract
The syndrome of acute bilateral basal ganglia lesions is a rarely described complication of uremia occurring typically in the setting of concurrent long-standing diabetes mellitus. Reversible symmetrical lesions located in basal ganglia found on brain magnetic resonance imaging are hallmarks of this syndrome. Clinical presentation includes parkinsonism and/or involuntary movements. The cause of this syndrome is largely unknown. Among the factors that are believed to contribute to its pathogenesis are uremic toxins, metabolic acidosis and diabetic microangiopathy. Here we report a patient with uremia and newly diagnosed diabetes, who developed the syndrome of acute bilateral basal ganglia lesions after an incidence of severe hypoglycemia induced by oral hypoglycemic agents. We consider hypoglycemia as a candidate trigger factor for the syndrome of acute bilateral basal ganglia lesions and highlight the importance of strict glucose control in uremic patients.
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Affiliation(s)
- Maciej Juryńczyk
- Department of Neurology, Medical University of Lodz, Kopcinskiego 22, 90-153 Lodz, Poland.
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Kumar G, Goyal MK. Lentiform Fork sign: a unique MRI picture. Is metabolic acidosis responsible? Clin Neurol Neurosurg 2010; 112:805-12. [PMID: 20615611 DOI: 10.1016/j.clineuro.2010.06.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 05/01/2010] [Accepted: 06/10/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Bilateral basal ganglia lesions are neither diagnostic nor pathognomonic of uremic encephalopathy (UE). Nonetheless, bilateral basal ganglia T2/FLAIR hyperintensities have been widely reported to be associated with UE. The aim of this study was to describe a unique neuroradiological sign seen on the MRI brain in UE, present a retrospective chart review of patients with UE over the past 10 years for evidence of similar MRI appearance, review literature for evidence of this sign, and generate a hypothesis to explain its pathophysiological basis. METHODS We describe a previously unreported and unique MRI picture, the Lentiform Fork sign, in a patient with UE. We conducted a focused retrospective chart review of patients with UE over the past 10 years, for evidence of similar MRI changes. We review literature (through PUBMED, OVID, and CENTRAL) for evidence of this sign and propose a hypothesis to explain the basis of this MRI sign. RESULTS We describe the Lentiform Fork sign in a patient with UE. Of our 21 retrospectively reviewed patients with UE who underwent MRI, only one had this sign. Literature review identified 22 patients with this sign who had various conditions, all associated with metabolic acidosis. Fourteen of these patients had documented evidence of severe metabolic acidosis. We propose the hypothesis that metabolic acidosis is the basis of this Lentiform Fork sign. CONCLUSION Lentiform Fork sign is a unique, previously unreported MRI picture that is seen not only in patients with UE but also in other conditions that result in metabolic acidosis, helping discriminate a specific etiology from the myriad of conditions that are lumped under the rubric of "basal ganglia hyperintensity." We propose the hypothesis that metabolic acidosis may be the key factor in the pathogenesis of this sign.
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Affiliation(s)
- Gyanendra Kumar
- Department of Neurology, University of Missouri-Healthcare, Columbia, MO, USA.
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Affiliation(s)
- Shu-Ming Wang
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
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LI JORDANYZ, YONG TUCKY, SEBBEN RUBEN, KHOO EEWIN, DISNEY ALEXPS. Bilateral basal ganglia lesions in patients with end-stage diabetic nephropathy (Brief Communication). Nephrology (Carlton) 2008; 13:68-72. [DOI: 10.1111/j.1440-1797.2007.00838.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Acute bilateral basal ganglia lesions in diabetic uraemia: diffusion-weighted MRI. Neuroradiology 2007; 49:1009-13. [DOI: 10.1007/s00234-007-0299-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Accepted: 07/23/2007] [Indexed: 10/22/2022]
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40
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Cheng HC, Chi LH, Wu JY, Hsieh TT, Pemg BY. Blindness and basal ganglia hypoxia as a complication of Le Fort I osteotomy attributable to hypoplasia of the internal carotid artery: a case report. ACTA ACUST UNITED AC 2007; 104:e27-33. [PMID: 17499529 DOI: 10.1016/j.tripleo.2007.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 12/27/2006] [Accepted: 01/11/2007] [Indexed: 11/29/2022]
Abstract
Le Fort I osteotomy is used as a surgical procedure for correction of maxillofacial deformities. The common complications of this procedure are hemorrhage and infection, with incidence of 6% to 9%. Blindness associated with Le Fort I osteotomy was reported in 8 patients. An 18-year-old female complained of loss of sight in the left eye after recovery from hypotensive general anesthesia. The visual field of the left eye was dark and only perceived some movement. She presented with motor dysfunction and regressive behavior 2 weeks later as a result of hypoxia of bilateral basal ganglia. Two months later, her visual acuity recovered gradually and regressive behavior improved. Carotid angiography showed congenital hypoplasia of the left internal carotid artery. We suspected that hypoplasia could cause hypoxia of the central nervous system.
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Affiliation(s)
- Hsin-Chung Cheng
- Department of Dentistry, Taipei Medical University Hospital, Taipei, Taiwan
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Kim TK, Seo SI, Kim JH, Lee NJ, Seol HY. Diffusion-weighted magnetic resonance imaging in the syndrome of acute bilateral basal ganglia lesions in diabetic uremia. Mov Disord 2007; 21:1267-70. [PMID: 16700013 DOI: 10.1002/mds.20932] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In this report, we have presented a diabetic patient with uremia, in which acute Parkinsonism occurred, coupled with acute mental confusion, after a sudden increase in blood urea nitrogen and serum creatinin levels. Diffusion-weighted magnetic resonance imaging revealed a unique cytotoxic-type edema in the bilateral basal ganglia during the acute phase. Signal alterations were shown to regress in accordance with the normalized apparent diffusion coefficient (ADC) values, but irreversible cystic degeneration developed in the globus pallidus, with the very low preceding ADC values.
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Affiliation(s)
- Taik-Kun Kim
- Department of Diagnostic Radiology, Korea University, College of Medicine, Seoul, Korea.
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Cupidi C, Piccoli F, La Bella V. Acute reversible parkinsonism in a diabetic-uremic patient. Clin Neurol Neurosurg 2006; 108:601-3. [PMID: 15885881 DOI: 10.1016/j.clineuro.2005.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 04/04/2005] [Accepted: 04/11/2005] [Indexed: 11/15/2022]
Abstract
Acute movement disorders with basal ganglia lesions have been recently described in diabetic-uremic patients of Asian descent. The process is often reversible, with a favourable clinical outcome. Metabolic (i.e. uremic toxins) and microangiopathic changes have been suggested to be involved in its pathophysiology, even though racial and/or genetic factors might play a role too. In this report, we present a Caucasian diabetic patient with a long-lasting mild uremia in which acute parkinsonism occurred after a steep and unexpected increase of the serum creatinine. The follow-up demonstrated a significant improvement of the neurological signs and symptoms, the creatinine level lowered close to the premorbid levels, and after several months the patient had fully recovered. Our case history suggests that this unusual clinical syndrome is most probably not restricted to Asian patients. Because its potentially favourable outcome, it should be regularly included in the differential diagnosis of acute movement disorders.
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Affiliation(s)
- Chiara Cupidi
- Department of Neurology and Psychiatry, University of Palermo, via G La Loggia, 1-90129 Palermo, Italy
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Lee PH, Shin DH, Kim JW, Song YS, Kim HS. Parkinsonism with basal ganglia lesions in a patient with uremia: Evidence of vasogenic edema. Parkinsonism Relat Disord 2006; 12:93-6. [PMID: 16256408 DOI: 10.1016/j.parkreldis.2005.07.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2005] [Revised: 07/29/2005] [Accepted: 07/29/2005] [Indexed: 11/25/2022]
Abstract
Parkinsonian syndromes associated with basal ganglia pathology have very rarely been reported in patients with end-stage renal failure. The nature and pathophysiology of the basal ganglia lesion responsible for parkinsonism were unknown. A 48-year-old man who had advanced renal failure developed disturbance of balance and gait and decreased spontaneity. Brain magnetic resonance (MR) imaging disclosed bilateral basal ganglia lesions. By the finding of diffusion-weighted image, the apparent diffusion coefficient map, MR angiography, and SPECT, we suggest that the basal ganglia lesions may be the result of vasogenic edema attributable to focal hyperemia secondary to abnormal dilatation of small vessels.
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Affiliation(s)
- Phil Hyu Lee
- Department of Neurology and Nephrology, College of Medicine, Ajou University, Suwon, South Korea.
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Barbara PG, Manuel B, Elisabetta M, Giorgio S, Fabio T, Valentina C, Emanuela M, Massimo B, Giuseppe S, Paolo SG. The suddenly speechless florist on chronic dialysis: the unexpected threats of a flower shop? Diagnosis: dialysis related Wernicke encephalopathy. Nephrol Dial Transplant 2005; 21:223-5. [PMID: 16280376 DOI: 10.1093/ndt/gfh990] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Brouns R, De Deyn PP. Neurological complications in renal failure: a review. Clin Neurol Neurosurg 2005; 107:1-16. [PMID: 15567546 DOI: 10.1016/j.clineuro.2004.07.012] [Citation(s) in RCA: 237] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 07/27/2004] [Accepted: 07/27/2004] [Indexed: 02/08/2023]
Abstract
Neurological complications whether due to the uremic state or its treatment, contribute largely to the morbidity and mortality in patients with renal failure. Despite continuous therapeutic advances, many neurological complications of uremia, like uremic encephalopathy, atherosclerosis, neuropathy and myopathy fail to fully respond to dialysis. Moreover, dialytic therapy or kidney transplantation may even induce neurological complications. Dialysis can directly or indirectly be associated with dialysis dementia, dysequilibrium syndrome, aggravation of atherosclerosis, cerebrovascular accidents due to ultrafiltration-related arterial hypotension, hypertensive encephalopathy, Wernicke's encephalopathy, hemorrhagic stroke, subdural hematoma, osmotic myelinolysis, opportunistic infections, intracranial hypertension and mononeuropathy. Renal transplantation itself can give rise to acute femoral neuropathy, rejection encephalopathy and neuropathy in graft versus host disease. The use of immunosuppressive drugs after renal transplantation can cause encephalopathy, movement disorders, opportunistic infections, neoplasms, myopathy and progression of atherosclerosis. We address the clinical, pathophysiological and therapeutical aspects of both central and peripheral nervous system complications in uremia.
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Affiliation(s)
- R Brouns
- Department of Neurology and Memory Clinic, Middelheim General Hospital, Antwerp, Belgium
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Abstract
The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.
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Affiliation(s)
- Fernando Alarcón
- Department of Neurology, Eugenio Espejo Hospital, P.O. Box 17-07-9515, Quito, Ecuador.
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Wang HC, Hsu JL, Shen YY. Acute Bilateral Basal Ganglia Lesions in Patients With Diabetic Uremia: An FDG-PET Study. Clin Nucl Med 2004; 29:475-8. [PMID: 15249822 DOI: 10.1097/01.rlu.0000132881.83830.f7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Head CT and MRI show characteristic changes in the syndrome of acute bilateral basal ganglia lesions in patients with diabetic uremia. However, they do not provide further insight into the underlying pathophysiology. To further clarify the biologic mechanism of the syndrome, F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 2 patients. METHODS PET studies were performed in 2 diabetic uremic patients with acute movement disorders. The cerebral glucose metabolic rates in these 2 patients were compared with 11 normal age-matched controls. The images were further analyzed with statistical parametric mapping to identify regions of significant metabolic abnormality. RESULTS The cases showed markedly reduced glucose metabolism in the bilateral basal ganglia, especially in the bilateral putamens, where the glucose uptake was nearly absent. CONCLUSIONS FDG-PET correlates better with the clinical conditions and provides more pathophysiological information than head CT or MRI scans in bilateral basal ganglia lesions in patients with diabetic uremia. We propose that acute exacerbation of a long-term glucose utilization failure in the basal ganglia cells produced these lesions.
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Affiliation(s)
- Han-Cheng Wang
- School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
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