Movement disorders as a manifestation of nonketotic hyperglycemia

Faciobrachial Myoclonus as the Presenting Manifestation of Diabetic Keto-Acidosis

Background:

Chorea and ballism are well-recognized acute potentially reversible movement disorders as the presenting manifestation of non-ketotic hyperglycemic states among older type-2 diabetics. Myoclonus as the form of presentation of diabetic keto-acidosis (DKA) in previously undiagnosed type-1 diabetic has never been reported before.

Case report:

We herein report the case of a 36-year-old previously healthy patient who presented with acute onset incessant faciobrachial myoclonus for 10 days. The patient was found to be suffering from DKA and eventually diagnosed as type-1 diabetes mellitus. Myoclonus disappeared with achieving euglycemia and did not recur.

Discussion:

Apart from expanding the spectrum of acute movement disorder among diabetics, this case reiterates the importance of rapid bedside measurement of capillary blood glucose in all patients presenting with acute onset abnormal movements irrespective of their past glycemic status. This simple yet life-saving approach can clinch the diagnosis at the earliest and thus will avoid costly investigations and mismanagement.

Hyperglycemia-induced seizures - Understanding the clinico- radiological association

Objectives:

To highlight the typical magnetic resonance imaging (MRI) findings in hyperglycemia-induced seizures and compare the results with similar previous studies with a brief mention of pathophysiological mechanisms.

Materials and Methods:

This retrospective study included medical and imaging records of six consecutive patients with hyperglycemia-induced seizures. The data analysis included a clinical presentation and biochemical parameters at admission. The MRI sequences were evaluated for region involved, presence of subcortical T2 hypo-intensity, cortical hyper-intensity, and restricted diffusion. Similar previous studies from the National Library of Medicine (NLM) were analyzed and compared with our study.

Results:

Twenty-four patients were included from four studies in previous literature for comparison. In our study, on imaging, posterior cerebral region was predominantly involved, with parietal involvement in 83.3%, followed by occipital, frontal, and temporal involvement in 33.3% patients compared with occipital in 58.3%, parietal in 45.8%, and frontal and temporal in 16.6% of patients in previous literature. The subcortical T2 hypo-intensity was present in 83.3% of the patients, cortical hyper-intensity in all patients, and restricted diffusion in 66.6% of the patients in our study compared with subcortical T2 hypo-intensity in 95.8% of the patients, cortical hyper-intensity in 62.5%, and restricted diffusion in 58.3% of the patients in previous literature.

Conclusion:

Although many etiologies present with subcortical T2 hypointensity, cortical hyperintensity, restricted diffusion, and postcontrast enhancement on MRI, the clinical setting of seizures in a patient with uncontrolled hyperglycemia, hyperosmolar state, and absence of ketones should suggest hyperglycemia-induced seizures to avoid misdiagnosis, unnecessary invasive investigations, and initiate timely management.

Advances in Knowledge:

Our study highlights the presence of posterior predominant subcortical T2, fluid-attenuated inversion recovery (FLAIR), and susceptibility-weighted angiography (SWAN) hypointensity; cortical hyperintensity; and restricted diffusion in hyperglycemia-induced seizures. The presence of T2 and SWAN hypointensity could support the hypothesis of possible deposition of free radicals and iron in the subcortical white matter.

Hypertension and Diabetes Are Associated With Clinical Characteristics in Patients Undergoing Microvascular Decompression for Hemifacial Spasm

OBJECTIVES

The aim of the present study is to investigate effect of hypertension and diabetes on neuroelectrophysiology, outcomes and complications in patients with hemifacial spasm (HFS) treated by microvascular decompression (MVD).

METHODS

From June 2014 to December 2016, 476 consecutive HFS patients who had undergone MVD were divided into 2 groups according to the presence or absence of comorbidities: diabetic group (n = 26) versus non-diabetic group (n = 450), and hypertensive group (n = 141) versus normotensive group (n = 335). Relevant patient data, including preoperative and postoperative neuroelectrophysiology, operative findings, outcome of MVD and complications, were collected and analyzed retrospectively over the 2-year follow-up period. The impact of hypertension and diabetes on the clinical features of HFS patients was investigated by using logistic regression models.

RESULTS

Brainstem auditory evoked potential (BAEP), postoperative prognosis and abnormal muscle response (AMR) were not different between any of the 2 groups. Preoperative positive AMR occurred more frequently in the nondiabetic group than diabetic group [OR = 0.202, P = 0.004], whereas hypertension was not independently predictive for neuroelectrophysiology in patients with HFS. Adjusted multivariate analysis indicated that hypertension was the only clinical factor associated with MVD-related complications [OR = 0.482, P = 0.007] and hearing impairment [OR = 0.28, P = 0.004] after various potential confounders were taken into account, whereas diabetes was not predictive for postoperative complications.

CONCLUSIONS

Diabetes is associated with low positive rate of preoperative AMR, thus weakening the predictive role of AMR for successful MVD. Hypertension may be an independent risk factor for hearing impairment after MVD.

Paroxysmal Dyskinesias

Paroxysmal dyskinesias (PD) are hyperkinetic movement disorders where patients usually retain consciousness. Paroxysmal dyskinesias can be kinesigenic (PKD), nonkinesigenic (PNKD), and exercise induced (PED). These are usually differentiated from each other based on their phenotypic and genotypic characteristics. Genetic causes of PD are continuing to be discovered. Genes found to be involved in the pathogenesis of PD include MR-1, PRRT2, SLC2A1, and KCNMA1. The differential diagnosis is broad as PDs can mimic psychogenic events, seizure, or other movement disorders. This review also includes secondary causes of PDs, which can range from infections, metabolic, structural malformations to malignancies. Treatment is usually based on the correct identification of type of PD. PKD responds well to antiepileptic medications, whereas PNKD and PED respond to avoidance of triggers and exercise, respectively. In this article, we review the classification, clinical features, genetics, differential diagnosis, and management of PD.

Paroxysmal movement disorders: An update

Paroxysmal movement disorders comprise both paroxysmal dyskinesia, characterized by attacks of dystonic and/or choreic movements, and episodic ataxia, defined by attacks of cerebellar ataxia. They may be primary (familial or sporadic) or secondary to an underlying cause. They can be classified according to their phenomenology (kinesigenic, non-kinesigenic or exercise-induced) or their genetic cause. The main genes involved in primary paroxysmal movement disorders include PRRT2, PNKD, SLC2A1, ATP1A3, GCH1, PARK2, ADCY5, CACNA1A and KCNA1. Many cases remain genetically undiagnosed, thereby suggesting that additional culprit genes remain to be discovered. The present report is a general overview that aims to help clinicians diagnose and treat patients with paroxysmal movement disorders.

Prediction of seizure control in non-ketotic hyperglycemic induced seizures

BACKGROUND

To study the factors predictive for seizure control in non-ketotic hyperglycemic induced seizures (NKHS).

METHODS

We studied 21 patients who were clinically diagnosed as NKHS at Khon Kaen University hospital, Thailand. Multiple linear regression analysis was used to identify the factors predictive for seizure control.

RESULTS

Most patients had no previous history of diabetes and presented with repetitive partial seizures. The mean number of seizure attacks was 45 times prior to admission. The average duration to terminate seizure was 36 hours and significantly predicted by frequency of seizures (estimate 0.9, p value 0.013).

CONCLUSION

Frequency of seizures is the only predictive factor for the success of seizure control in NKHS.

Non Ketotic Hyperosmolar Hyperglycemia presenting as Epilepsia Partialis Continua. (An unusual presentation of a common disorder)

We report a patient with epilepsia partialis continua (EPC) associated with non ketotic hyperosmolar hyperglycemia. EPC is uncommon presenting clinical finding during nonketotic hyperglycemia. This case was reported in Medical Intensive Care Unit (MICU) in Hamad Medical Corporation, Doha, Qatar.

Diagnosing Epilepsy in the Elderly

Elderly individuals represent the fastest-growing segment of the US population. Seizures are common among elderly persons, and the etiology, clinical presentation, and prognosis of seizure disorders can often differ between elderly patients and younger individuals. However, published information regarding the diagnosis and management of epilepsy in elderly patients is scarce. Because a number of conditions that are common in elderly patients may resemble epilepsy, diagnosis can be challenging. Cardiovascular conditions, migraines, drug effects, infections, metabolic disturbances, sleep disorders, and psychiatric disorders are all associated with signs and symptoms that may often mimic epilepsy. New paradigms must be put into practice to establish an accurate diagnosis in the elderly patient; besides an initial evaluation, the patient history and an electroencephalogram should be obtained. Proper diagnosis is essential for proper treatment in the elderly patient.

A unique case of reversible hyperglycemic Holmes' tremor

Various movement disorders are known manifestations of nonketotic hyperglycemia (NKH). Hyperglycemic tremors are rare, with only two cases resembling flapping tremors reported in literature. We present a unique case of reversible hyperglycemic Holmes' tremor associated with NKH and postulate the underlying pathophysiology of this condition.

[Epileptic seizures in non-ketotic hyperglycemia]

Seizures are common in hyperglycemia and are often the first manifestation particularly in non-ketotic hyperglycemia (NKH). Published reports emphasize partial motor seizures almost exclusively. Here we present the clinical, biological and electrophysiological features of 22 consecutive patients with NKH who developed focal seizures and were treated in our department. Neurological exam was normal in 15 cases. When abnormal, it showed postictal obnubilation or diabetic polyneuropathy. Interictal EEG (obtained in 17 patients) showed focal or generalised slowing in 65% of cases, and ictal EEG (six patients) showed rapid spikes most often unilateral. CTs were normal in 77% of cases, and showed age-compatible cortico-subcortical atrophy in the others. All patients were alert, with glucose values between 13.6 and 55 mmoles/l and osmolarity values increased in all cases to a mild or moderate extent (266-309.20 mosm/l). Three out of 22 patients (14%) presented with motor epilepsy partialis continua. In 11/22 cases (50%), diabetes mellitus had not been diagnosed previously. Seizures associated with NKH were resistant to anticonvulsant treatment but responded well to insulin therapy and rehydration. They subsided completely in an average of 4 days, and only one patient had to be transiently transferred to ICU. We conclude on the importance of an early diagnosis of this condition to prevent malignant evolution of the epileptic syndrome into a state of hyperosmolarity and coma associated with a much higher mortality.

Secondary paroxysmal dyskinesias

Paroxysmal dyskinesias (PxDs) are involuntary, episodic movements that include paroxysmal kinesigenic (PKD), paroxysmal nonkinesigenic (PNKD), and paroxysmal hypnogenic (PHD) varieties. Although most PxDs are primary (idiopathic or genetic), we found 17 of our 76 patients with PxD (22%) to have an identifiable cause for their PxD (10 men; mean age, 41.4 years). Causes included peripheral trauma (in three patients), vascular lesions (in four), central trauma (in four), kernicterus (in two), multiple sclerosis (in one), cytomegalovirus encephalitis (in one), meningovascular syphilis (in one), and migraine (in one). The latency from insult to symptom onset ranged from days (trauma) to 18 years (kernicterus), with a mean of 3 years. Nine patients had PNKD, two had PKD, five had mixed PKD/PNKD, and one had PHD. Hemidystonia was the most common expression of the paroxysmal movement disorder, present in 11 patients. Both of the patients with PKD had symptom durations of <5 minutes. Symptom duration ranged from 10 seconds to 15 days for PNKD and from 5 minutes to 45 minutes for mixed PKD/PNKD. There were no uniformly effective therapies, but anticonvulsant drugs, clonazepam, and botulinum toxin injections were the most beneficial. Awareness of the variable phenomenology and the spectrum of causes associated with secondary PxD will allow for more timely diagnosis and early intervention.

Hemiballismus as a presenting sign of hyperglycemia

A 53-year-old man arrived at the emergency department after the onset of progressive hemiballismus. This movement disorder was the only manifestation of his hyperglycemic state. Prompt recognition of the association of unusual movement disorders with nonketotic hyperglycemia will allow for prompt treatment.

Paroxysmal dyskinesia associated with hypoglycemia

The association of movement disorders with hypoglycemia has been rarely noted in the past. We recently observed 2 patients with documented hypoglycemia and paroxysmal dyskinesias. One patient had evidence of an insulin-secreting tumor. The other patient had insulin-dependent diabetes, and also experienced recurrent episodes of hypoglycemic hemiparesis. Classical adrenergic symptoms of hypoglycemia were absent in both patients. Our observations support the concept that the development of neuroglycopenic symptoms cannot be predicted from blood glucose measurements alone, but must depend on other factors controlling the availability or metabolism of glucose in the brain.