Hemichorea-hemiballism as the first presentation of type 2 diabetes mellitus

Relationship Between Diabetic Chorea and Timing of MRI Findings: A Systematic Review with Case Reports

Background

Diabetic chorea is a rare complication of diabetes mellitus for which head MRI is the most common diagnostic imaging modality. Cases have been reported where CT and/or MRI findings are inconsistent or clinical symptoms and imaging findings do not appear simultaneously. We aimed to compile the cases in which imaging findings appeared on MRI retests and to examine in a systematic review whether temporal differences in the appearance of imaging findings correlate with clinical characteristics.

Case Presentation

An 80-year-old man with type 2 diabetes mellitus came to a hospital with abnormal movements of the left upper and lower extremities. Two days after the first visit, his symptoms flared up, and his head MRI showed an old cerebral infarction and no new lesion. On day 14, he retested T1-weighted imaging and showed a high signal in the right putamen, which was considered diabetic chorea. Blood glucose was controlled with insulin, and the involuntary movements disappeared.

Methods

PubMed and ICHUSHI were searched to identify patients with diabetic chorea who had undergone MRI retests. Patients grouped by the temporal change in the presence/absence of imaging findings were compared on age, sex, duration of diabetes mellitus, blood glucose level, HbA1c level, side of involuntary movement, time to first MRI, and follow-up MRI.

Results

Of the 64 cases analyzed, 43 (67.2%) were female. The mean age was 69.0 years. 16 (25.0%) had worsening findings upon MRI retesting, 37 (57.8%) had improvement, and 10 (15.6%) had unchanged findings. There were no significant differences in age, sex, mean blood glucose level or HbA1c at onset among the groups.

Conclusion

There was no association between the pattern of appearance of imaging findings over time and clinical characteristics, including glucose levels. If initial MRI findings are negative, MRI retesting after a certain time may help diagnose diabetic chorea.

Hemichorea-Hemiballismus Syndrome in Acute Non-ketotic Hyperglycemia

Hemichorea/hemiballismus syndrome secondary to non-ketotic hyperglycemia is a movement disorder induced by long-standing poor control of diabetes mellitus. Diagnosis is based on clinical assessment and imaging. Here we report a rare case of a 56-year-old woman presenting with involuntary movements on the left side secondary to acute hyperglycemia. She received antidiabetic and anti-choreic drugs. The patient's glycemic profile was closely monitored, and she, consequently, responded favorably to therapy.

Nonketotic Hyperglycemic Chorea in a 10-Year-Old Asian Boy with Diabetes Mellitus

Nonketotic hyperglycemic chorea-ballism (NKHCB), also known as diabetic striato-pathy (DS) by some, is a rare complication of diabetes mellitus and uncommon in children. We reported a case of a 10 11/12-year-old male child of Asian descent with uncontrolled type 1 diabetes mellitus (T1DM), Hashimoto's thyroiditis, and multiple food allergies presenting with bilateral chorea-ballism. His brain magnetic resonance imaging revealed developmental venous anomaly in right parietal lobe and right cerebellum, no focal lesions or abnormal enhancements. Choreiform movements resolved with correction of hyperglycemia. Children and adolescents with a movement disorder should be evaluated for diabetes mellitus, especially with increasing prevalence and insidious nature of T2DM associated with obesity.

"Diabetic striatopathy": clinical presentations, controversy, pathogenesis, treatments, and outcomes

Diabetic striatopathy (DS) is a rare medical condition with ambiguous nomenclature. We searched PubMed database from 1992 to 2018 for articles describing hyperglycemia associated with chorea/ballism and/or neuroimages of striatal abnormalities. Descriptive analysis was performed on demographic/clinical characteristics, locations of striatal abnormalities on neuroimages, pathology findings, treatment strategies, and outcomes. In total, 176 patients (male:female = 1:1.7) were identified from 72 articles with mean age 67.6 ± 15.9 (range, 8-92). Among them, 96.6% had type 2 DM with 17% being newly diagnosed. Average blood glucose and glycated hemoglobin concentrations were 414 mg/dL and 13.1%, respectively. Most patients (88.1%) presented with hemichorea/hemiballism. Isolated putamen and combined putamen-caudate nucleus involvements were most common on neuroimaging studies with discrepancies between CT and MRI findings in about one-sixth of patients. Unilateral arm-leg combination was the most frequent with bilateral chorea in 9.7% of patients. Chorea and imaging anomalies did not appear concomitantly in one-tenth of patients. Successful treatment rates of chorea with glucose-control-only and additional anti-chorea medications were 25.7% and 76.2%, respectively, with an overall recurrence rate being 18.2%. The most commonly used anti-chorea drug was haloperidol. To date, four out of six pathological studies revealed evidence of hemorrhage as a probable pathogenesis.

Inherited or acquired metabolic disorders

This chapter starts with a description of imaging of inherited metabolic disorders, followed by a discussion on imaging of acquired toxic-metabolic disorders of the adult brain. Neuroimaging is crucial for the diagnosis and management of a number of inherited metabolic disorders. Among these, inherited white-matter disorders commonly affect both the nervous system and endocrine organs. Magnetic resonance imaging (MRI) has enabled new classifications of these disorders that have greatly enhanced both our diagnostic ability and our understanding of these complex disorders. Beyond the classic leukodystrophies, we are increasingly recognizing new hereditary leukoencephalopathies such as the hypomyelinating disorders. Conventional imaging can be unrevealing in some metabolic disorders, but proton magnetic resonance spectroscopy (MRS) may be able to directly visualize the metabolic abnormality in certain disorders. Hence, neuroimaging can enhance our understanding of pathogenesis, even in the absence of a pathologic specimen. This review aims to present pathognomonic brain MRI lesion patterns, the diagnostic capacity of proton MRS, and information from clinical and laboratory testing that can aid diagnosis. We demonstrate that applying an advanced neuroimaging approach enhances current diagnostics and management. Additional information on inherited and metabolic disorders of the brain can be found in Chapter 63 in the second volume of this series.

Post-stroke dyskinesias

Strokes, whether ischemic or hemorrhagic, are among the most common causes of secondary movement disorders in elderly patients. Stroke-related (vascular) movement disorders, however, are uncommon complications of this relatively common disease. The spectrum of post-stroke movement disorders is broad and includes both hypo- and hyperkinetic syndromes. Post-stroke dyskinesias are involuntary hyperkinetic movements arising from cerebrovascular insults and often present with mixed phenotypes of hyperkinesia which can sometimes be difficult to classify. Nevertheless, identification of the most relevant motor phenotype, whenever possible, allows for a more specific phenomenological categorization of the dyskinesia and thus helps guide its treatment. Fortunately, post-stroke dyskinesias are usually self-limiting and resolve within 6 to 12 months of onset, but a short-term pharmacotherapy might sometimes be required for symptom control. Functional neurosurgical interventions targeting the motor thalamus or globus pallidus interna might be considered for patients with severe, disabling, and persistent dyskinesias (arbitrarily defined as duration longer than 12 months).

Nonketotic hyperglycemic chorea

This is a unique case of nonketotic hyperglycemic (NKH) chorea in a 34-year-old white male. The patient had a poorly controlled type 2 diabetes mellitus (DM) due to medication incompliance. He complained of polyuria, polydipsia, and weight loss of 20 pounds within a month before presentation. T2-weighted (T2W) MRI showed hyperintensity in the left basal ganglion. Glycated hemoglobin (HBA1c) was 13.6%. The patient was started on insulin and clonazepam and the chorea resolved after proper control of the glucose level. To our knowledge, this is the first reported case of NKH chorea in a young white male with high T2-weighted (T2W) magnetic resonance signal in the basal ganglia.

Acute chorea and type 1 diabetes mellitus: clinical and neuroimaging findings

The association of type 1 diabetes mellitus (T1DM) and acute chorea is rare. We report an 8-yr-old boy with T1DM who developed acute hemichorea-hemiballism of the right arm in whom magnetic resonance imaging (MRI) of the brain revealed hyperintense signal in putamen and considerable atrophy and focal area of gliosis in the right putamen. There was a deposition of deoxyhemoglobin indicating recent bleeding in the left lentiform nucleus. A control MRI 2 months later showed complete reabsorption of the blood component in the left lentiform nucleus. Multislice computerized tomography revealed hyperdensities in the corpus striatum and subcortical calcifications. This report describes, for the first time, findings of calcifications in the corticomedullary junction in the brain hemispheres of a child with T1DM and chorea and reviews the possible causal mechanisms of this unusual association.

Hypoglycemia-induced hemichorea in a patient with Fahr's syndrome

Non-ketotic hyperglycemia may be a cause of hemiballism-hemichorea. We present an elderly female type II diabetic patient with right-sided hemiballism-hemichorea of acute onset during hypoglycemia following insulin overtreatment of non-ketotic hyperglycemia. Brain computerized tomography and magnetic resonance imaging scans revealed characteristic hyperdensity and T1 hyperintensity, respectively, in the left basal ganglia, in addition to pallido-dentate calcifications, suggestive of Fahr's syndrome. Although extremely rare, hypoglycemia may be a cause of hemiballism-hemichorea especially in the presence of predisposing factors such as previous hyperglycemic episodes and Fahr's syndrome.

A prospective series of patients with hyperglycaemia-associated movement disorders

Hyperglycaemia-associated movement disorders (MD) usually appear in older patients with diabetes and are related to acute peaks in blood glucose levels. This study aimed to describe the clinical features of a prospective series of patients with movement disorders associated with hyperglycaemia. We present a series of seven women and three men diagnosed with hyperglycaemia-associated MD who were followed for at least 1 year. Clinical evolution, treatment and neuroimaging findings are presented. Mean (± standard deviation [SD]) of the age at onset was 67.7 ± 11.7 years and mean (± SD) fasting glucose was 359.7 ± 162.5mg/dL. Putaminal hyperintensity on T1-weighted MRI was present in almost all instances. Two patients had pontine lesions compatible with osmotic myelinolysis. At follow-up, eight patients had a complete remission. We conclude that the clinical profile of patients in our series is similar to those reported in the literature. No clinical or metabolic features were found to be correlated with remission. Similarities with osmotic myelinolysis syndromes are discussed as an alternative aetiological hypothesis.

[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.