A gemistocytic astrocytoma demonstrated high intensity on MR images. Protein hydration layer

Diabetic striatopathy: an updated overview of current knowledge and future perspectives

PURPOSE

Diabetic striatopathy (DS) is a rare complication of poorly controlled diabetes mellitus (DM), characterized by hyperglycemia associated with chorea/ballism and characteristic reversible basal ganglia abnormalities on computed tomography (CT) and/or magnetic resonance imaging (MRI). We propose a narrative review of the literature on this topic, currently unknown to most, and about which physicians should be aware. We intend to summarize, critically review, and take to mean the evidence on this disorder, describing its typical features.

METHODS

We searched Pubmed for English-language sources using the following keywords in the title and the abstract: diabetic striatopathy, hyperglycemic non-ketotic hemichorea/hemiballism, chorea/hemichorea associated with non-ketotic hyperglycemia, diabetic hemiballism/hemichorea, chorea, hyperglycemia, and basal ganglia syndrome. We collected scientific articles, including case reports, reviews, systematic reviews, and meta-analyses from the years 1975 to 2023. We eliminated duplicate, non-English language or non-related articles.

RESULTS

Older Asian women are more frequently affected. Suddenly or insidiously hemichorea/hemiballism, mainly in the limbs, and high blood glucose with elevated HbA1c in the absence of ketone bodies have been observed. Furthermore, CT striatal hyperdensity and T1-weighted MRI hyperintensity have been observed. DS is often a treatable disease following proper hydration and insulin administration. Histopathological findings are variable, and no comprehensive hypothesis explains the atypical cases reported.

CONCLUSION

DS is a rare neurological manifestation of DM. If adequately treated, although treatment guidelines are lacking, the prognosis is good and life-threatening complications may occur occasionally. During chorea/hemiballism, we recommend blood glucose and HbA1c evaluation. Further studies are needed to understand the pathogenesis.

[Gemistocytic astrocytomas]

Gemistocytic astrocytomas (GA) are a variant of diffuse astrocytomas GII (WHO, 2016). Like all diffuse astrocytomas, GA recur with time, which is often accompanied by malignant degeneretion into the anaplastic astrocytoma GIII or to the secondary glioblastoma GIV. However, the progression-free survival and overall survival in patients with GA is less than in patients with diffuse astrocytomas. Given that this group of patients, according to the WHO classification (2016), is classified as GII, patients with GA usually do not receive comprehensive treatment. We have conducted a thorough analysis of research on this problem for the period from 1956 to 2017. Differences in the histological pattern, immunohistochemical and molecular-genetic profiles, survival of patients with GA and diffuse astrocytomas GII are shown there. A clinical case of a patient with transformation of a diffuse astrocytoma in GA (GIII) and then into a secondary glioblastoma is presented.

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

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

Choreoathetosis associated with non-chetotic hyperglycemia

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.

Definition and diagnostic implications of gemistocytic astrocytomas: a pathological perspective

Gemistocytic astrocytoma still continues to be enigmatic; both in terms of definition and prognostic implications. The major issue of contention has been the clinical relevance of this pathological entity. The currently accepted definition of gemistocytic astrocytoma requires 20% or more gemistocytes, and considers the neoplasm as a diffuse astrocytoma, which is a WHO grade II tumor. Some suggest that gemistocytic morphology should be considered as evidence of a higher grade astrocytoma. However, there is no consensus on the percentage of gemistocytes associated with a worse prognosis than otherwise expected. Given the reported cases and series, it is not clear that this morphology portends a more aggressive biology when all else is equal. There is still a need for studies with sufficient numbers of well-matched gemistocytic and non-gemistocytic astrocytic neoplasms to decide whether upgrading a tumor with 'significant' number of gemistocytes is justifiable. This article presents a critical review of the existing studies and a brief mention of our experience from a pathological perspective.

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.