1
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Yap KH, Baharudin NH, Gafor AHA, Remli R, Lim SY, Zaidi WAW, Azmin S, Mukari SAM, Khalid RA, Ibrahim NM. Movement Disorders Resulting From Bilateral Basal Ganglia Lesions in End-Stage Kidney Disease: A Systematic Review. J Mov Disord 2022; 15:258-263. [PMID: 35614016 PMCID: PMC9536908 DOI: 10.14802/jmd.21185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The basal ganglia (BG) are susceptible to fluctuations in blood urea levels, sometimes resulting in movement disorders. We described patients with end-stage kidney disease (ESKD) presenting with movement disorders associated with bilateral BG lesions on imaging. Methods We report four patients and systematically reviewed all published cases of ESKD presenting with movement disorders and bilateral BG lesions (EBSCOhost and Ovid). Results Of the 72 patients identified, 55 (76.4%) were on regular dialysis. Parkinsonism was the most common movement disorder (n = 39; 54.2%), followed by chorea (n = 24; 33.3%). Diabetes mellitus (n = 51; 70.8%) and hypertension (n = 16; 22.2%) were the most common risk factors. Forty-three (59.7%) were of Asian ethnicity. Complete clinical resolution was reported in 17 (30.9%) patients, while 38 (69.1%) had incomplete clinical resolution with relapse. Complete radiological resolution occurred in 14 (34.1%) patients. Conclusion Movement disorders associated with BG lesions should be recognized as a rare and potentially reversible metabolic movement disorder in patients with ESKD.
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Affiliation(s)
- Kah Hui Yap
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | | | | | - Rabani Remli
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Shahrul Azmin
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
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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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3
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Mansoor S, De Klerk L, Lineen J, Fahad M, Ali I, Coffey B, Mulry MA, Saadat S, Kelly S, Adenan MH, Murphy K. Lentiform fork sign in a uremic patient with a high anion gap metabolic acidosis with seizures: a case report from North West of Ireland. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00234-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Lentiform fork sign is a neuroradiological abnormality which is encountered in the clinical practice associated with uremic encephalopathy, dialysis disequilibrium syndrome and metabolic acidosis.
Case presentation
We describe here a case of this neuro-radiological abnormality which was encountered in a patient with uraemia and high anion gap metabolic acidosis who presented with generalised convulsion and later had some tremor in her hands. In our patient, there were few predisposing factors which might have possibly resulted in this abnormality chronic kidney disease, diabetes mellitus, and metabolic acidosis.
Conclusion
The Lentiform fork sign is a rare occurrence which can be related to a long list of toxic and metabolic causes but in conjunction with metabolic acidosis in chronic kidney disease patients, it can narrow down this list of alternate diagnosis.
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4
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Jaryal A, Thakur S, Pathania JS, Vikrant S, Kumar D, Verma L. Lentiform fork sign: Uremia alone or multifactorial causation? Hemodial Int 2019; 24:E10-E12. [PMID: 31840926 DOI: 10.1111/hdi.12810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 11/28/2022]
Abstract
Neurological complications are common in patients with acute or chronic renal failure, especially when there is marked reduction in the glomerular filtration rate (GFR). One such clinical syndrome, uremic encephalopathy (UE), occurs due to widespread dysfunction of central nervous system (CNS). It manifests with myriad clinical features and usually is suggested by bedside elicitation of asterixis (flapping tremor). Symptomatic involvement of the basal ganglia manifesting as choreoathetosis and clinical and radiological resolution with hemodialysis has been reported in the medical literature, but only rarely. The present report details such a case.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Suresh Thakur
- Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, India
| | | | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Dinesh Kumar
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
| | - Lokesh Verma
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
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5
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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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6
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Viggiano D, Wagner CA, Blankestijn PJ, Bruchfeld A, Fliser D, Fouque D, Frische S, Gesualdo L, Gutiérrez E, Goumenos D, Hoorn EJ, Eckardt KU, Knauß S, König M, Malyszko J, Massy Z, Nitsch D, Pesce F, Rychlík I, Soler MJ, Spasovski G, Stevens KI, Trepiccione F, Wanner C, Wiecek A, Zoccali C, Unwin R, Capasso G. Mild cognitive impairment and kidney disease: clinical aspects. Nephrol Dial Transplant 2019; 35:10-17. [PMID: 31071220 DOI: 10.1093/ndt/gfz051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Davide Viggiano
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland and National Center of Competence in Research (NCCR) Kidney CH, Switzerland
| | - Peter J Blankestijn
- Department of Nephrology, University Medical Center, Utrecht, The Netherlands
| | - Annette Bruchfeld
- Department of Renal Medicine, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Danilo Fliser
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Medical Centre, Homburg, Germany
| | - Denis Fouque
- Department of Nephrology, Dialysis, Nutrition, Centre Hospitalier Lyon Sud, Université de Lyon, F-69495 Pierre Bénite Cedex, France
| | | | - Loreto Gesualdo
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico, Bari and University 'Aldo Moro' of Bari, Bari, Italy
| | - Eugenio Gutiérrez
- Department of Clinical Medicine, Center of Functionally Integrative Neuroscience, University of Aarhus, Aarhus, Denmark
| | | | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Samuel Knauß
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Germany
| | - Maximilian König
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Ziad Massy
- Division of Nephrology, Ambroise Paré Hospital, APHP, Paris-Ile-de-France-West University (UVSQ), Boulogne Billancourt/Paris, INSERM U1018 Team5, Villejuif, France
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Francesco Pesce
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico, Bari and University 'Aldo Moro' of Bari, Bari, Italy
| | - Ivan Rychlík
- First Department of Internal Medicine, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Maria Jose Soler
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Nephrology Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Former Yugoslav, Republic of Macedonia
| | - Kathryn I Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Francesco Trepiccione
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy.,Department of Genetic and Translational Medicine, Biogem, Ariano Irpino, Italy
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital, Wuerzburg, Germany
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Robert Unwin
- Centre for Nephrology, University College London (UCL), Royal Free Campus, London, UK.,AstraZeneca IMED ECD CVRM R&D, Gothenburg, Sweden
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy.,Department of Genetic and Translational Medicine, Biogem, Ariano Irpino, Italy
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7
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Unstable blood sugar levels as triggers for the syndrome of acute bilateral basal ganglia lesions in diabetic uremia: Two Taiwanese patients with unusual neuroimaging findings. eNeurologicalSci 2019; 14:85-88. [PMID: 30723812 PMCID: PMC6352294 DOI: 10.1016/j.ensci.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/24/2022] Open
Abstract
The syndrome of acute bilateral basal ganglia lesions in diabetic uremia is uncommon and usually affects Asian patients. The underlying pathogenesis of this syndrome is not clear. We searched PUBMED using the keywords “bilateral basal ganglia”, “diabetic”, and “uremia”, and found a total of 34 cases from 1998 to 2016. In most cases, blood sugar levels were normal. Here we report two Taiwanese cases presenting with dyskinesias. In one case the syndrome was triggered by hyperglycemia, and in the other by severe hypoglycemia. Their neuroimaging findings were unusual as compared with previously reported cases, presenting as mixed hypo- and hyperintensity on T1-weighted magnetic resonance imaging. We think these new finding would shed some light on the underlying pathophysiology of this syndrome. For treatment, it is advisable to keep glucose levels as stable as possible in diabetic uremic patients to prevent this syndrome. A rapid correction of hyper- or hypoglycemia after the onset may help recovery. Syndrome of acute bilateral basal ganglia lesions in diabetic uremia presenting with dyskinesias. Hyperglycemia and hypoglycemia can trigger this syndrome. Mixed hypo- and hyperintensity on T1-weighted MRI.
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8
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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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9
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Jung JH. Bilateral Basal Ganglia Lesions in a Dialytic Patient with Diabetes and Recurrent Hypoglycemia. Chonnam Med J 2019; 55:173-174. [PMID: 31598478 PMCID: PMC6769242 DOI: 10.4068/cmj.2019.55.3.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/06/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jong Hwan Jung
- Division of Nephrology, Department of Internal Medicine, Wonkwang University School of Medicine and Hospital, Iksan, Korea
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10
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Jabbari B, Vaziri ND. The nature, consequences, and management of neurological disorders in chronic kidney disease. Hemodial Int 2017; 22:150-160. [PMID: 28799704 DOI: 10.1111/hdi.12587] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perhaps no other organ in the body is affected as often and in as many ways as the brain is in patients with chronic kidney disease (CKD). Several factors contribute to the neurological disorders in CKD including accumulation of uremic toxins, metabolic and hemodynamic disorders, oxidative stress, inflammation, and impaired blood brain barrier among others. The neurological disorders in CKD involve both peripheral and central nervous system. The peripheral neurological symptoms of CKD are due to somatic and cranial peripheral neuropathies as well as a myopathy. The central neurological symptoms of CKD are due to the cortical predominantly cortical, or subcortical lesions. Cognitive decline, encephalopathy, cortical myoclonus, asterixis and epileptic seizures are distinct features of the cortical disorders of CKD. Diffuse white matter disease due to ischemia and hypoxia may be an important cause of subcortical encephalopathy. A special and more benign form of subcortical disorder caused by brain edema in CKD is termed posterior reversible encephalopathy. Subcortical pathology especially when it affects the basal ganglia causes a number of movement disorders including Parkinsonism, chorea and dystonia. A stimulus-sensitive reflex myoclonus is believed to originate from the medullary structures. Sleep disorder and restless leg syndrome are common in CKD and have both central and peripheral origin. This article provides an overview of the available data on the nature, prevalence, pathophysiology, consequences and treatment of neurological complications of CKD.
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Affiliation(s)
- Bahman Jabbari
- Department of Neurology, Division of Movement disorders, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nosratola D Vaziri
- Departments of Medicine, Physiology and Biophysics, Division of Nephrology and Hypertension, University of California, Irvine, USA
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11
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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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12
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Yoon JE, Kim JS, Park JH, Lee KB, Roh H, Park ST, Cho JW, Ahn MY. Uremic parkinsonism with atypical phenotypes and radiologic features. Metab Brain Dis 2016; 31:481-4. [PMID: 26631408 DOI: 10.1007/s11011-015-9774-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
Uremic encephalopathy with bilateral basal ganglia lesions has been reported as an acute neurometabolic disease which shows reversible clinical course and brain imaging features. The exact nature and pathophysiology have not been well established. We encountered two patients who showed a relapsing and aggravating course and an atypical phenotype including parkinsonism with paroxysmal dystonic head tremor and acute onset monoparesis of the lower extremity. They also showed unusual radiological findings which revealed combined lesions in the basal ganglia and cortex, persistent hemorrhagic transformation, and focal ischemic lesion in the internal capsule. Herein, we present the unusual phenomenology with atypical radiologic findings and suggest the possible multifactorial pathogenesis of uremic encephalopathy.
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Affiliation(s)
- Jee-Eun Yoon
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Republic of Korea
| | - Ji Sun Kim
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Republic of Korea.
| | - Jeong-Ho Park
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Bucheon Hospital, Seoul, South Korea
| | - Kyung-Bok Lee
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Republic of Korea
| | - Hakjae Roh
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Republic of Korea
| | - Sung Tae Park
- Department of Radiology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Jin Whan Cho
- Department of Neurology, Sungkyunkwan University School of Medicine, Seoul,, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
| | - Moo-young Ahn
- Department of Neurology, Soonchunhyang University School of Medicine, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Republic of Korea.
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13
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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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14
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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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15
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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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16
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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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17
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Reversible acute chorea in a patient with diabetes treated with hemodialysis. J Clin Neurosci 2012; 19:1179. [PMID: 22658668 DOI: 10.1016/j.jocn.2012.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 01/27/2012] [Indexed: 11/24/2022]
Abstract
Chorea is an abnormal hyperkinetic movement disorder. The reasons for chorea are diverse and include hereditary, endocrine, toxic, vascular, infectious, autoimmune, and metabolic etiologies. We present a 64-year-old woman with acute chorea who suffered from diabetes with recurrent hypoglycemia, and chronic renal failure treated by hemodialysis. The full clinical recovery, negative work-up and disappearance of basal ganglia lesions on the follow-up imaging emphasize the transient character of encephalopathy expressed by acute chorea in patients with diabetes treated with hemodialysis.
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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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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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Dicuonzo F, Di Fede R, Salvati A, Palma M, de Mari M, Baldassarre GD, Di Renzo B, Tortorella C. Acute extrapyramidal disorder with bilateral reversible basal ganglia lesions in a diabetic uremic patient: diffusion-weighted imaging and spectroscopy findings. J Neurol Sci 2010; 293:119-21. [PMID: 20381073 DOI: 10.1016/j.jns.2010.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Revised: 02/26/2010] [Accepted: 03/05/2010] [Indexed: 11/30/2022]
Abstract
Acute movement disorders associated with bilateral lesions in the basal ganglia are increasingly described in patients affected by diabetes and uremia. Pathophysiology has not been utterly understood yet, but it is likely to be multifactorial, with both ischemic/microvascular and metabolic/toxic factors determining the lesions and symptoms. We have studied a uremic diabetic patient who was admitted in emergency after presenting choreic movements, in which CT and MR, including diffusion-weighted imaging and spectroscopy, showed bilateral symmetric basal ganglia lesions with regression at follow-up. This is the first report in the literature describing spectroscopic findings in this condition.
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Affiliation(s)
- Franca Dicuonzo
- Department of Neurological and Psychiatric Sciences, University of Bari, Bari, Italy
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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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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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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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