Non-ketotic hyperglycaemia hemichorea–hemiballismus and acute ischaemic stroke

Abstract

Here we describe a patient with a rare movement disorder, hemichorea–hemiballismus, which is described as a complication of non-ketotic hyperglycaemia. This complication may be seen in individuals with poorly controlled long-standing diabetes mellitus. Proper diagnosis is established with CT and MRI of the brain, which typically show classic findings in the basal ganglia. Treatment focuses on improvement of glycaemic control and usually results in rapid resolution of the movement disorder. Nevertheless, recurrent episodes of hemichorea–hemiballismus, and even more ominous complications such as ischaemic stroke may occur.

One Side of the Story; Clues to Etiology in Patients with Asymmetric Chorea

“…A 5-year-old boy with a prior right-hemispheric stroke developed left-sided chorea when he developed vitamin D deficiency leading to hypocalcemia and hypomagnesemia [ 61 ]. Several cases of hyperglycemic hemichorea also followed this pattern, where previous focal lesion or asymmetric white matter injury seemed to predispose to unilateral basal ganglia overactivity [ 61 66 67 ]. Hypoparathyroidism has been associated with hemiballismus, but this was in the setting of extensive calcifications of the basal ganglia which, while grossly symmetric, were assumed to be the true underlying cause for the abnormal movements [ 68 ].…”

“…One uniting theme is that of asymmetric blood flow and microscopic ischemic injury increasing vulnerability to systemic insult. In the case of hyperglycemic HC/HB there are clear macroscopic cases, such as pre-existing severe large vessel stenosis [ 130 ] or stroke, [ 66 67 ]. In most cases, however, the changes appear to be chronic and microscopic with suggestion of long term injury on pathology [ 41 42 ] that is not readily seen by MRI and therefore is hard to prove.…”

Diabetic Striatopathy Complicated With Acute Ischemic Stroke: A Case Report

“…A few patients developed persistent chorea even under a backdrop of well-controlled diabetes mellitus or complete resolution of abnormal striatum signals, suggesting the presence of irreversible damage (Ahlskog et al, 2001 ; Wu et al, 2014 ; Roy et al, 2016 ; Lucassen et al, 2017 ; Chatterjee et al, 2022 ). Severe or uncontrolled hyperglycemia is associated with chorea relapse and the attacks of acute cerebrovascular events, such as acute cerebral infarction and hemorrhage, leading to a poor prognosis (Carrion and Carrion, 2013 ; Lucassen et al, 2017 ; Chua et al, 2020 ; Dong and Zhang, 2021 ). Carrion et.…”

Hemiballismus in Patients With Poorly Controlled Type 2 Diabetes Mellitus

“…While the exact etiology remains unclear, the hyperintensity is hypothesized to be related to metabolic derangements caused by hyperviscosity of the blood in the small end arteries feeding the basal ganglia. 3,11 These abnormalities in turn interrupt the signaling cascade with abnormal firing rates or firing patterns, leading to reduced inhibition of the motor thalamus and ultimately present as hemiballismus. 1,3,7 While most cases presented with unilateral hyperkinesis and associated contralateral basal ganglia abnormalities, there are reports of both unilateral and bilateral movements associated with bilateral basal ganglia hyperintensities on imaging.…”

“…Noncontrast computed tomography (CT) shows well-defined unilateral increased density in the contralateral basal ganglia without mass effect. 1,9,11 This report aims to illustrate and enhance the understanding of hemiballismus associated with hyperglycemia. One patient presented to the US Department of Veterans Affairs (VA) Bay Pines VA Healthcare System (BPVAHCS) in Florida, which motivated us to search for other similar cases.…”