Non-Ketotic Hyperglycemia Induced Hemichorea-Hemiballism May Represent Glioma-Like Pattern On Multimodal Magnetic Resonance Imaging: Can 1H Spectroscopy Help In The Differentiation?

Background: Non-ketotic hyperglycemia (NKH) induced hemichorea-hemiballismus (HC-HB) is a rare reversible condition predominantly found in elderly patients with poorly controlled diabetics. Here, we describe two cases of NKH induced HC-HB with distinctive morphological and functional changes on conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI) and 1H magnetic resonance spectroscopy (MRS).Case presentation: In case 1 with NKH induced HC-HB, computer tomography depicted increased attenuation in the left putamen and caudate nucleus. Focal T2-hyperintensity, obvious mass effect and ring-like enhancement were revealed on conventional MRI, suggesting the imaging findings of glioma. DWI indicated the lesion with unrestricted diffusion of water molecule. MRS further illustrated markedly increased lactate (Lac) and lipids (Lip), slightly elevated choline (Cho), and slightly decreased N-acetylaspartate (NAA) within the lesion. In case 2, baseline and follow-up MRI showed a lesion with typical reversible signal intensity in the right putamen without mass effect.Conclusions: This report emphasizes that NKH induced HC-HB may exhibit a unique appearance mimicking glioma. Slightly elevated Cho/NAA ratio with marked increased Lac peak on MRS may help to exclude neoplastic diseases.

Non-Ketotic Hyperglycemia-Induced Hemichorea-Hemiballism, A Case Presentation

Hemiballism is a rare hyperkinetic movement disorder characterized by repetitive, uncontrolled movements unilateral /or bilateral extremities, develops as a result of insult to the contralateral basal ganglia. The leading source for this disorder is ischemia, followed by non-ketotic hyperglycemia with poorly controlled diabetes. Non-ketotic hyperglycemic induced hemichorea-hemiballism is an uncommon but unique etiology of unilateral neuro-parenchymal findings restricted to corpus striatum (caudate nucleus and putamen). Nonketotic hyperglycemia-induced hemichorea-hemiballism diagnosed by Cross-sectional imaging modalities (Computed tomography and Magnetic resonance imaging), Clinical results (hemichorea-hemiballism), Laboratory tests (elevated blood glucose and hemoglobin A1c levels).

Recurrent Facial Focal Seizures With Chronic Striatopathy and Caudate Atrophy—A Double Whammy in an Elderly Woman With Diabetes Mellitus

Seizures and involuntary movements are relatively rare, but well-known neurological complications of non-ketotic hyperglycemia. While hemichorea-hemiballism secondary to diabetic striatopathy is increasingly being reported, unilateral caudate atrophy resulting from chronic vascular insufficiency/insult in a backdrop of poorly controlled diabetes mellitus is sparsely described in literature. We herein report a 75-year-old woman with poorly controlled diabetes mellitus who presented with concurrent epilepsia partialis continua involving left side of her face and hemichorea on the right side in the context of non-ketotic hyperglycemia. Neuroimaging revealed a space-occupying lesion suggestive of low-grade glioma in the right superior frontal cortex and left-sided caudate atrophy as well. Possibly, space-occupying lesion in motor cortex acted as an inciting factor for seizures and non-ketotic hyperglycemia further lowered the seizures threshold. On the other hand, atrophied left caudate had led to persistent choreiform movements secondary to chronic uncontrolled hyperglycemia. The simultaneous presence of acute and chronic neurological complications of diabetes mellitus makes this case unique. It also highlights the need for strict control of blood glucose and utility of appropriate neuroimaging to rapidly diagnose and prevent further complications.

HEMICHOREA-HEMIBALLISMUS INDUCED BY NON-KETOTIC HYPERGLYCEMIA: CASE REPORT

Non-ketotic hyperglycemia with hemichorea-Hemiballismus (HGSC) is a rare complication of a non-equilibrated diabetic disease characterized by a continuous rapid, non-rhythmic, involuntary unilateral movement of the extremities, caused in most cases by decreased activity of the contralateral subthalamic nucleus of the basal ganglia. It may reveal undiagnosed diabetes. We describe here the case of an 84-year-old Moroccan woman followed for type 2 diabetes mellitus under treatment, who presented with abnormal movements of the right half-body. Laboratory tests showed higher blood glucose levels, urinary ketones were negative, brain CT without injection showed high density in the basal ganglia on the left side.

Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review

Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.

Chorea in a Non-Ketotic Hyperglycemic State: Case Report

Context: Non-ketotic hyperglycemia is a rare cause of chorea. Clinical findings are usually unilateral and potentially reversible after treatment for hyperglycemia. Hyperglycemia leads to asymmetric multifocal petechial hemorrhages of the basal ganglia, leading to a dysfunction of neuronal networks that connect the basal ganglia and the motor cortical areas, mainly affecting the subthalamic nucleus and contralateral striatum, which is highlighted by typical hyperdense lesions of the basal ganglia in computed tomography (CT) of the brain. This study aimed to report a case of a patient with choreiform movements due to a rare etiology of hyperglycemia nonketotic in a Hospital Public of Joinville, SC. The study was carried out through the collection and analysis of a patient’s medical record. Case report: Female patient, 54 years old, who presented for 6 days choreiform movements in the face, left upper limb and, discreetly, in the left lower limb. Snake tongue sign and milkmaid’s grip positive, without dysarthria. In the laboratory exam, glucose of 600 mg / dL; without further changes. Cranial tomography showed hyperdensity in the putamen region on the right. The treatment was started to obtain better glycemic control and Risperidone 3 mg / day. Conclusions: It is concluded, then, that non-ketotic hyperglycemia is an uncommon, but reversible cause of chorea, and may manifest itself due to an uncontrolled non-ketotic diabetes mellitus. Its pathogenic mechanism remains to be clarified. In addition, clinical, epidemiological, imaging and laboratory findings, together, corroborate for early diagnosis and proper management.