Putaminal petechial haemorrhage as the cause of chorea: a neuroimaging study

Further learning of clinical characteristics and imaging manifestations of nonketotic hyperglycemic hemichorea

OBJECTIVE

To summarize the clinical characteristics and imaging manifestations of patients with nonketotic hyperglycemic hemichorea (NH-HC) and to explore the possible pathogenesis, diagnosis. and treatment of the disease in order to improve the understanding of this disease and avoid misdiagnosis.

METHODS

Retrospective analysis was performed on the case data of five patients with NH-HC admitted to our hospital in recent years. The patients were treated in the department of endocrinology, department of neurology, and department of neurosurgery in our hospital, respectively. Meanwhile, relevant literatures were consulted for further learning.

RESULTS

NH-HC is usually presented as a triad of nonketotic hyperglycemia, lateral chorea, and typical imaging manifestations of head magnetic resonance imaging or computed tomography, but the clinical manifestations are not the same, and imaging features may also be different, presenting a diversified trend in clinical practice. All five patients were given glucose-lowering drugs and improved with or without combination of drugs to control symptoms of chorea.

CONCLUSION

NH-HC is a rare complication of diabetes, characterized by hyperglycemia and hemichorea. How to identify the extreme situation and make fast judgment is a top priority. Timely and correct control of blood glucose is the key to the treatment, and when necessary, application of dopamine receptor antagonists in patients with combination therapy can accelerate improvement of the clinical symptoms. The prognosis of NH-HC is good, the clinician should strengthen comprehensive understanding of this disease to avoid missed diagnosis or misdiagnosis and enable patients to get more timely and effective treatment.

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.

Hemiplegia due to hypoglycaemia followed by haemicorea after correction of glycaemic values

A 69-year-old man suffered from hemiplegia of the left limb due to hypoglycaemia. After 3 h of oral supplementation with sugar water, the patient recovered from hemiplegia but then presented symptoms of haemichorea. To our knowledge, a case of abnormal glucose metabolism complicated with two types of motor disturbance has not been reported previously.

Atypical Imaging Findings of Nonketotic Hyperglycemic Hemichorea: A Case Report and Review of the Literature

Nonketotic hyperglycemic hemichorea (NH-HC) is a rare condition presenting in the clinical setting. Brain imaging plays an important role in diagnosing NH-HC, which typically shows basal ganglia changes contralateral to the side of the hemiballismus/hemichorea. Only a few articles in the literature have reported normal pertinent magnetic resonance/CT findings in patients presenting with NH-HC. To the authors' knowledge, no cases in the literature have reported basal ganglia changes solely observed on CT but not on MRI in patients presenting with NH-HC. Herein, we describe a unique case in which a CT of a patient presenting with NH-HC demonstrated basal ganglia abnormalities with negative MRI findings.

Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management

Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.

Clinical manifestation of non-ketotic hyperglycemia chorea: A case report and literature review

INTRODUCTION

Chorea is considered a special complication of diabetes mellitus. Here we report a case of chorea associated with non-ketotic hyperglycemia (NKH).

PATIENT CONCERNS

The patient was a 79-year-old Asian woman. She had a history of type 2 diabetes mellitus more than 30 years, but with a poor control of blood sugar. She complained of acute onset of right limb involuntary activities, and being admitted to neurology department.

DIAGNOSIS

The patient was then diagnosed with NKH chorea.

INTERVENTIONS

Intravenous infusion of insulin was given to reduce blood glucose. Haloperidol was used to control motor symptoms.

OUTCOMES

Her symptoms improved quickly after treatment. In the past year, the patient's blood sugar was well controlled and her chorea did not recur.

LESSONS

If there are sudden abnormal movements in patients, in addition to thinking of chorea, hepatolenticular degeneration and other diseases, we should also pay attention to blood sugar, especially in diabetic patients with poor blood sugar control and negative ketone, we should consider the possibility of NKK chorea.

CONCLUSIONS

NKH chorea is a special complication of diabetes.

Poststroke Parkinsonism associates with an increased mortality risk in patients

Background

To determine whether poststroke Parkinsonism (PSP) increases mortality risk in poststroke patients by using Taiwan National Health Insurance Research Database (NHIRD).

Methods

We analyzed NHIRD data of ≥40-year-old patients diagnosed as having stroke [International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes 430-438] between 2000 and 2013. Poststroke patients were divided into those with subsequent PSP (ICD-9-CM codes 332, 332.0, and 332.1) and without PSP (non-Parkinsonism, PSN) cohorts, all compared with a sex-, age-, comorbidity-, and index date-matched comparison cohort. We calculated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of all-cause mortality risk in these cohorts after adjustments for age, sex, and comorbidities.

Results

PSP was noted in 11.87% (1,644/13,846) of poststroke patients. In the PSN, PSP, and comparison cohorts, mortality incidence rates were 69.1, 124.9, and 38.8 per 1,000 person-years, respectively. Compared with the comparison cohort, the mortality risks in patients aged 40 to 64, 65 to 74, and ≥75 years were respectively 2.21-, 1.91-, and 1.86-fold higher mortality risks in the PSN cohort and 4.57-, 2.84-, and 2.27-fold higher mortality risks in the PSP cohort. Male sex further increased mortality risk in poststroke patients with PSP.

Conclusions

Long-term all-cause mortality risk is increased by 1.39 times in poststroke patients with PSP than in those without. Our findings depict vital information in incidence and risk of PSP. Those would aid clinicians and the government to improve future poststroke care.

Hyperglycaemic chorea-ballism or unmasking of Huntington's chorea in a patient with diabetes

Chorea-ballism is a neurological syndrome characterised by violent involuntary movements of one or both extremities. In the last decades, several patients with these involuntary movements were reported in association with hyperglycaemia. Here, we present a unique case of possible Huntington's disease, which could have been unmasked by the hyperglycaemic insult to the basal ganglia in a 64-year-old man who presented with chorea-ballism.

Diabetic Striatopathy in Childhood: A Case Report

Diabetic striatopathy is a well-known complication of diabetes in adults. To our knowledge, only 2 cases have been reported in children. We here report the case of a teenager in whom diabetic striatopathy was revealed by the subacute appearance of hemichorea-hemiballism in the context of weight loss, polyuria, and polydipsia. Glycemia control allowed rapid clinical recovery despite established striatal lesions documented on MRI. We also discuss current hypotheses about pathophysiological processes underlying this entity.

Non-ketotic hyperglycemia unmasks hemichorea

Background

Chorea can be caused by a variety of diseases, including neurodegenerative disorders, vascular events, toxic-metabolic states, and immunologic and infectious diseases. We describe a patient who presented with hemichorea as the initial manifestation of Diabetes Mellitus (DM) and responded partially to the glycemic control.

Case report

A 63-year-old, healthy Hispanic man with no prior history of medical illness presented with subacute onset, gradually progressive hemichorea of 6 weeks’ duration. On evaluation, he was found to have non-ketotic hyperglycemia with high serum glucose (328 mg/dL), elevated hemoglobin A1C (9.9%), and absent ketones. Magnetic Resonance Imaging of the brain demonstrated hyper intense signals in bilateral basal ganglia on T1W images. He was diagnosed to have DM. Despite optimal glycemic control with insulin, the patient continued to have hemichorea at 3 months follow-up and required haloperidol for control of the involuntary movements.

Significance

Involuntary movements, particularly hemichorea, can be a manifestation and rarely be a presenting sign of DM.

Hemichorea associated with nonketotic hyperglycemia: clinical and neuroimaging features in 12 patients

BACKGROUND

Nonketotic hyperglycemia is a rare cause of hemichorea. Patients with hemichorea associated with nonketotic hyperglycemia (HCNH) always have a favorable prognosis when given prompt treatment.

METHODS

We reviewed the medical records of 12 patients with HCNH in our hospital between January 2005 and January 2013. The clinical data, laboratory findings, and imaging features of the patients were collected.

RESULTS

All 12 patients were admitted to the hospital with a complaint of involuntary movements. Ten patients had a history of diabetes, while the other 2 patients had not been diagnosed. The mean level of blood glucose on admission was 330.7 ± 107.8 mg/dl, and the ketones were negative. A cranial computed tomography scan showed hyperdensity in the striatum, which quickly resolved. Magnetic resonance imaging showed hyperintensity on T1-weighted images without change over several months. Nearly all of the patients experienced relief from the hemichorea symptoms after correcting hyperglycemia with a combination of dopamine receptor inhibitors and the sedative lorazepam, if necessary.

CONCLUSION

HCNH is a benign disorder, the pathogenesis of which remains unclear. Radiologic changes can provide guidance for early treatment and generally give an estimation of the degree of injury.

Movement disorders in cerebrovascular disease

Movement disorders can occur as primary (idiopathic) or genetic disease, as a manifestation of an underlying neurodegenerative disorder, or secondary to a wide range of neurological or systemic diseases. Cerebrovascular diseases represent up to 22% of secondary movement disorders, and involuntary movements develop after 1-4% of strokes. Post-stroke movement disorders can manifest in parkinsonism or a wide range of hyperkinetic movement disorders including chorea, ballism, athetosis, dystonia, tremor, myoclonus, stereotypies, and akathisia. Some of these disorders occur immediately after acute stroke, whereas others can develop later, and yet others represent delayed-onset progressive movement disorders. These movement disorders have been encountered in patients with ischaemic and haemorrhagic strokes, subarachnoid haemorrhage, cerebrovascular malformations, and dural arteriovenous fistula affecting the basal ganglia, their connections, or both.

Permanent haemichorea associated with transient hyperglycemia

Hyperglycemia is associated with several common neurological syndromes. Chorea, however, is a rare association that has only been documented in the literature recently. The triad of chorea, non-ketotic hyperglycemia and a high signal basal ganglia lesion on the T1 weighted brain MRI (C-H-BG) is considered to be a unique syndrome. C-H-BG refers to the onset of chorea during or shortly after (days to weeks) an episode of non-ketotic hyperglycemia. There is usually a high signal lesion in the basal ganglia on T1 weighted brain MRI that corresponds to the location of the chorea. Most case reports of C-H-BG have been described in Asians. C-H-BG is considered to be a benign condition in which the clinical and MRI signs resolve quickly upon correction of blood glucose levels. Here, the authors describe a case of C-H-BG in a middle aged Caucasian in whom the chorea did not resolve with improved glycemic control.

[Nonketotic hyperglycemia-induced hemiballism]

Nonketotic hyperglycemia-induced hemichorea or hemiballism is a well-recognized entity that is rarely encountered. Particular computed tomography and magnetic resonance imaging findings have been described. The pathophysiological mechanism of this disease remains uncertain. We report here on two female patients that presented with hemiballism secondary to nonketotic hyperglycemia and underwent brain computed tomography and magnetic resonance imaging.

Vascular chorea in adults and children

Chorea may occur as part of the symptomatology of acute stroke; it occasionally also may be delayed or progressive. Patients with vascular-related chorea typically present with an acute or subacute onset of chorea of one side of the body (hemichorea), contralateral to the lesion. Cerebrovascular disease is the most common cause of sporadic chorea. Lesions are most frequently found in the thalamus and lentiform nucleus, and less often in subthalamic nucleus. The differential diagnosis of choreic syndromes relies not so much on differences in the phenomenology of the hyperkinesia but the age at onset, mode of onset, time course, family history, drug use, distribution of chorea in the body, and presence of accompanying neurological findings. Magnetic resonance imaging is preferred to demonstrate the presence of strategic small lesions in regions that are difficult to image with computed tomography, such as the globus pallidus, thalamus, and subthalamic nucleus. Although the prognosis of hemichorea can be benign, the long-term prognosis is not specifically determined by the hemichorea but by the long-term prognosis of stroke patients. Symptomatic treatment with antichoreic drugs may be necessary in the acute phase. Surgery is rarely indicated to treat vascular chorea.

[Hemiballism-hemichorea with non-ketotic hyperglycemia: movement disorder related to diabetes mellitus]

Diabetes mellitus, especially when not under control, can lead to several neurological complications being the development of involuntary movements one of the rarest presentations. Nonketotic hyperglycemia in aged patients who present with ballismus-chorea movements and cerebral image alterations in computerized tomography (CT) and magnetic resonance constitute a syndrome of recent characterization and few cases in literature. We present a case of a 75 year-old male patient admitted with history of hemiballismus-hemichorea movements, hyperglycemia, glycated hemoglobin of 14.4% and CT with a hyperdense area in the topography of the right basal ganglia. After glycemic control, the neurological signs resolved completely and the initial hyperdense lesion disappeared.

Lesions in basal ganglia in a patient with involuntary movements as a first sign of diabetes - case report and review of the literature

We present a case of unilateral hyperdensity of the lentiform and caudate nucleus on CT with hyperintesity on T1-weighted images on MRI in a 71-year-old woman with hemichorea-hemiballism and recently diagnosed diabetes.

Hyperglycemic choreoathetosis: role of the putamen in pathogenesis

Hyperglycemic choreoathetosis (HC) is an uncommon syndrome often associated with hyperintensity of the basal ganglia on MRI. We performed a retrospective review of cases with HC to characterize the clinical, biochemical, and neuroimaging (CT, MRI, and MR spectroscopy) findings and to propose a mechanism for this syndrome. Seven HC patients with a mean age of 75.1 years, mean blood glucose of 27.4 mmol/L, and mean plasma osmolarity of 313.4 mmol/L were studied. All had MR-T1 hyperintensity of the putamen on the side contralateral to the choreoathetosis. Two patients had additional hyperintensity of the globus pallidus while one also had involvement of the caudate. On MR-T2, 2 patients showed hyperintensity, 2 isointensity, and 3 hypointensity in the putamen. MR spectroscopy showed elevated choline and reduced N-acetylaspartate; two patients also had elevated myoinositol levels. Our findings suggest that the putamen has a central role in HC, and MR spectroscopy supports neuronal dysfunction in the putamen. Biochemical and neuroimaging findings support hyperviscosity as the most plausible mechanism.

Hemichorea-hemiballismus associated with nonketotic hyperglycemia: a possible role of inflammation

Three cases of hemichorea-hemiballismus (HC-HB) associated with nonketotic hyperglycemia were reported. Of them two patients presented as HC-HB and the remaining one as generalized chorea-ballismus (CB). Brain MRI showed characteristic T1-weighted high-intensity lesions in the contralateral or bilateral striatum without edema or mass effect. They all had a prior history of respiratory or urinary infection. Cerebrospinal fluid test in two patients showed an elevation of protein concentration with normal cell and an increased IgG content and elevated IgG index or 24 h IgG intrathecal synthesis rate. These results suggested that inflammation within the central nervous system may participate in the pathogenesis of chorea and ballismus induced by NKH.

Acute onset hemichorea-hemiballism. MRI signal abnormality in a metabolically normal patient. A case report

Abnormal signals involving the basal ganglia on MR images have been reported with new-onset hemichorea-hemiballism, typically in elderly Asian patients. The most common cause is a vascular lesion, but many cases are reported in association with hyperglycemia. We describe one case of acute onset chorea-hemiballism with abnormal MRI signal in the basal ganglia but with no systemic abnormality.

Hemiballism due to hyperglycemic hyperosmolar syndrome

Non-ketotic hyperglycemia has occasionally been associated with various neurological abnormalities including movement disorders. Hyperglycemic hyperosmolar syndrome (HHS) is the second most common cause of hemiballism-hemichorea, which is due to a contralateral putaminal lesion. We describe a 95-year-old woman with HHS who developed hemichorea-hemiballism syndrome due to a putaminal lesion.

Subthalamic lesion on MR imaging in a patient with nonketotic hyperglycemia-induced hemiballism

SUMMARY

Hemiballism with corresponding striatal T1 hyperintensity on MR imaging has occasionally been reported in patients with nonketotic hyperglycemia. However, the subthalamic nucleus lesion, which is believed to be pathogenetically related to hemiballism, is rarely documented in a living patient with nonketotic hyperglycemia. We describe a patient with nonketotic hyperglycemia-induced hemiballism, whose responsible lesion (ie, the subthalamus) was demonstrated by MR imaging.

Oro-bucco-lingual dyskinesia associated with nonketotic hyperglycaemia

Nonketotic hyperglycaemia is typically associated with a hemiballism-hemichorea pattern of involuntary movement and is characterized by hyperintense signal within the contralateral striatum on T(1)-weighted magnetic resonance imaging (MRI). An oro-bucco-lingual syndrome and location of the lesions has not been previously described. Herein, we report a patient with oro-bucco-lingual dyskinesia associated with nonketotic hyperglycaemia. MRI revealed characteristic T(1) hyperintense lesions in the bilateral putamen.

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.

Chorea and Broca aphasia induced by diabetic ketoacidosis in a type 1 diabetic patient diagnosed as Moyamoya disease

We here report one case of hemichorea and Broca aphasia occurred with diabetic ketoacidosis. A 20-year-old woman with type 1 diabetes mellitus had experienced diabetic ketoacidosis fourth time after the onset of diabetes. At the third ketoacidotic episode, the patient was admitted to our hospital for the first time to show hemichorea of the left extremities. Brain computed tomography (CT) demonstrated a high-density area in the right caudate head and low-density area in the right putamen. Magnetic resonance angiography (MRA) demonstrated a stenosis at the root of the bilateral middle and anterior cerebral arteries. The hemichorea disappeared within 3 days. At the fourth ketoacidotic episode, not hemichorea but unconsciousness was there for 2 days even after ketoacidosis disappeared. After the unconscious state, Broca aphasia was demonstrated for 15 days. The cerebral angiography showed a finding compatible to Moyamoya disease. These findings support that chorea and Broca aphasia induced by diabetic ketoacidosis was developed in addition to blood vessel abnormalities such as Moyamoya disease. We suggest that poorly controlled diabetic patients with hemichorea should undergo cerebral angiography.

Post-stroke movement disorders: report of 56 patients

BACKGROUND

Although movement disorders that occur following a stroke have long been recognised in short series of patients, their frequency and clinical and imaging features have not been reported in large series of patients with stroke.

METHODS

We reviewed consecutive patients with involuntary abnormal movements (IAMs) following a stroke who were included in the Eugenio Espejo Hospital Stroke Registry and they were followed up for at least one year after the onset of the IAM. We determined the clinical features, topographical correlations, and pathophysiological implications of the IAMs.

RESULTS

Of 1500 patients with stroke 56 developed movement disorders up to one year after the stroke. Patients with chorea were older and the patients with dystonia were younger than the patients with other IAMs. In patients with isolated vascular lesions without IAMs, surface lesions prevailed but patients with deep vascular lesions showed a higher probability of developing abnormal movements. One year after onset of the IAMs, 12 patients (21.4%) completely improved their abnormal movements, 38 patients (67.8%) partially improved, four did not improve (7.1%), and two patients with chorea died. In the nested case-control analysis, the patients with IAMs displayed a higher frequency of deep lesions (63% v 33%; OR 3.38, 95% CI 1.64 to 6.99, p<0.001). Patients with deep haemorrhagic lesions showed a higher probability of developing IAMs (OR 4.8, 95% CI 0.8 to 36.6).

CONCLUSIONS

Chorea is the commonest movement disorder following stroke and appears in older patients. Involuntary movements tend to persist despite the functional recovery of motor deficit. Deep vascular lesions are more frequent in patients with movement disorders.

Striatal hyperintensity on T1-weighted magnetic resonance images and high-density signal on CT scans obtained in patients with hyperglycemia and no involuntary movement. Report of two cases

The authors report on two patients in whom an increased signal on T1-weighted magnetic resonance images and a high-density signal on computerized tomography scans of the striatum were demonstrated, both of which were associated with nonketotic hyperglycemia. Involuntary movements, which have been present in all previously reported cases, were not observed in either patient at any time during the entire course of illness. One patient displayed hemiparesis, whereas the other had dementia, gait disturbance, and urinary incontinence. Clinical and radiological abnormalities improved on control of blood glucose levels. Invasive studies, including biopsy procedures, should be avoided on encountering this disease given the good prognosis that results from simple medical treatment.

Unilateral putaminal CT, MR, and diffusion abnormalities secondary to nonketotic hyperglycemia in the setting of acute neurologic symptoms mimicking stroke

A 75-year-old Asian man presented with two episodes of chorea associated with nonketotic hyperglycemia. His chorea rapidly resolved after restitution of a normal serum glucose level, although an MR image obtained at the time of acute symptoms demonstrated high signal intensity on T1-weighted images, low signal intensity on T2-weighted images, and restricted diffusion, all involving the left putamen. A CT scan obtained 1 month later demonstrated faint hyperattenuation of the involved putamen. The reported pathophysiologic considerations for these imaging features are reviewed, and an original explanation is proposed.

Hemiballism: revisiting a classic disorder

Hemiballism is a rare movement disorder that presents with unilateral flinging movements of the limbs. In traditional teaching, it has been characterised as almost pathognomonic of a lesion in the subthalamic nucleus (STN). The prognosis was described as grave, with severe disability and death in many cases. However, review of more recent reports shows that the STN is directly involved in only a minority of cases. The prognosis is benign in most cases, with almost all patients responding well to treatment and many having spontaneous remission, although long-term prognosis of cerebrovascular disease may not be so good. There have also been recent insights into the pathophysiology of hemiballism, which have emphasised the importance of altered firing patterns in basal-ganglia structures. Recent studies have pointed to previously unrecognised causes, particularly non-ketotic hyperosmolar hyperglycaemia and complications of HIV infection, that may account for a substantial proportion of cases of hemiballism.

Fluid-attenuated inversion-recovery imaging of hemichorea

I report a young man with hemichorea in whom fluid-attenuated inversion-recovery images alone showed signal change.

Influence of tiapride on platelet counts in healthy volunteers and patients with movement disorders

BACKGROUND

The selective D2 antagonist tiapride is administered in various movement disorders. Furthermore, there are indications that tiapride increases platelet counts.

AIM

To characterize tiapride's potential to increase platelet counts in healthy subjects and patients with movement disorders.

METHODS

In Part A, 10 healthy volunteers received tiapride (300 mg/day) for 21 days in a longitudinal, prospective, open trial. One hundred healthy subjects served as controls. Part B was a retrospective analysis of 15 patients with movement disorders on tiapride [Huntington's disease (n=6), Morbus Little (n=3), hyperkinetic syndromes of undetermined etiology (n=3), blepharospasm (n=1), cervical dystonia (n=1), perioral dyskinesia (n=1)] and 15 age- and sex-matched controls.

RESULTS

Part A: Although serum prolactin levels increased by 526+/-14%, confirming good drug compliance, tiapride elicited only minor changes in platelet counts. Part B: Platelet counts correlated positively with the dose of tiapride (100-800 mg/day; r=.67; P=.007). Platelet counts were significantly higher in patients on tiapride compared to healthy age-matched controls (P<.001). Four patients responded to an increase in the tiapride dosage with an increase in platelet count by 97-173 cells/nl.

CONCLUSION

Three weeks of treatment with tiapride (300 mg/day) is insufficient to elevate platelet counts to a clinically relevant extent in young healthy volunteers. However, in elderly patients with movement disorders tiapride treatment is associated with markedly increased platelet counts.

Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases

BACKGROUND

Chorea associated with non-ketotic hyperglycemia and high signal intensity lesions on T1-weighted brain magnetic resonance images (C-H-BG) is recognized as a unique syndrome that affects elderly women exclusively. However, its overall clinical features are unclear.

MATERIAL AND METHODS

The literature describing patients with C-H-BG from 1985 to 2001 was reviewed using MEDLINE. Their clinical features and those of four patients with C-H-BG at this hospital were analyzed.

RESULTS

This study included 49 patients from the literature and four patients at this hospital. Their mean age at the onset was 71.1 years (range=22-92 years). Women were affected more frequently than men (men/women=17:30). The mean serum glucose level measured after the onset of chorea was 481.5 mg/dl (ranging from 169 to 1264), HbA1c level was 14.4% (ranging from 9.9 to 19.2), and the serum osmolarity was 305.9 mmol/kg (ranging from 291 to 335). Forty-seven patients developed hemichorea. Six patients developed bilateral chorea, and magnetic resonance imaging (MRI) showed bilateral basal ganglia lesions. MRI showed that putamen was involved in all cases (isolated putamen=31 patients, additional basal ganglia lesions=22 patients). None had lesions confined to the caudate nucleus or the globus pallidus. In all, except one, the anterior limb of the internal capsule was spared. Follow-up MRI studies were performed in 22 patients. In most, hemichorea improved along with the disappearance of the lesions. In 39 patients, chorea had ameliorated completely. The remaining 14 cases showed some improvement during the follow-up period. The chorea recurred in seven patients.

CONCLUSION

C-H-BG is a benign disorder affecting the elderly. It affects men much more frequently than has been reported. The high signal intensity basal ganglia lesion on the T1-weighted brain MRI study was reversible, and correlated with the clinical improvement in chorea.

Ipsilateral putamen hyperintensity on T1-weighted MRI in non-ketotic hyperglycemia with hemiballism-hemichorea: a case report

Movement disorders are often caused by lesions in the contralateral basal ganglia. This report presents an elderly woman with hemiballism-hemichorea induced by non-ketotic hyperglycemia, whose brain CT revealed a hyperdense lesion over the ipsilateral putamen. Concomitantly, MR image revealed a putaminal hyperintensity on T1-weighted image and hypointensity on T2-weighted image. A follow-up brain CT 4months after remission of the hyperkinesia revealed that the abnormal intensity had been completely resolved.

Non-ketotic hyperglycemia in a young woman, presenting as hemiballism-hemichorea

We report a 22-year-old girl presenting with acute onset left sided hemiballism-hemichorea (HH) and non-ketotic hyperglycemia (NKH). Initial brain CT revealed faint hyperdensities, sharply confined to the contralateral nucleus caudatus and putamen. Sequential MRI investigations yielded increasing hypersignal intensities on T1-weighted images and resolving hypodensities on T2-weighted images of the right striatum, leaving small sequelae in the head of the right caudate nucleus. NKH is an unusual cause of HH. The abnormalities seen in neuroimaging are rare, but seem to be quite specific to this syndrome. We give an update on current literature regarding the possible pathophysiological processes underlying this specific clinical entity.

Blood brain barrier destruction in hyperglycemic chorea in a patient with poorly controlled diabetes

A case of hemichorea in a patient with poorly controlled diabetes is reported. T1-weighted magnetic resonance imaging (MRI) showed an unusual homogeneous high-intensity area in the corpus striatum. Of interest in the case was the fact that the globus pallidus, which was enhanced with gadolinium at the onset of hemichorea, showed homogeneous high-intensity on a subsequent T1-weighted image. This indicated that blood brain barrier destruction preceded the signal intensity change in the basal ganglia. As far as the authors could determine, this is the first reported case showing such enhancement during the course of diabetic hemichorea.