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糖尿病患者於基底核疑似出血性變化的電腦斷層表現

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糖尿病患者於基底核疑似出血性變化的電腦斷層表現

High attenuation of basal ganglia lesion mimicking ICH in CT in

patient with diabetes

陳家慶, 林家葳, 劉建佑, 陳維恭

中國醫藥大學附設醫院 急診部

Introduction: We presented a case finally diagnosed as diabetic hemichorea-hemiballism (HCHB) with normal blood

glucose level and initially brain computed tomography(CT) showed mimic basal ganglion hemorrhage.

Case Report: This 60-year-old male with diabetes mellitus, type 2 under medicine control in recent 2 days. He

presented to our emergency department due to abnormal involuntary movements in his left upper limb for 2 days. He also complained of bilateral hands numbness and left side was predominant. There was no limb weakness, no facial palsy, no slurred speech, no unsteady gait and no obvious other focal sign. Blood tests showed unremarkable finding, including normal blood sugar level. Bain CT showed faint hyperattenuation of the entire right basal gangion which is easily confused with intracranial hemorrhage(figure1). Brain MRI after admission showed right basal ganglion T1-hyperintensity with neuronal loss, suggestive of chorea associated with non-ketotic hyperglycemia(figure2). His symptom got improvement gradually, and he was discharged on day 11.

Discussion: Hemichorea-hemiballism (HCHB) is usually continuous, but may be intermittent, and it may occur with

other types of involuntary movements, such as dystonia, myoclonus, or orofacial gestures1. The causes of HCHB

include hemorrhagic or ischemic stroke, neoplasm, systemic lupus erythematosus, hyperglycemic hyperosmolar state (HHS), Wilson’s disease, and thyrotoxicosis2. It has been reported in different states of diabetes mellitus such as

nonketotic hyperglycemia3,4. It also has been reported in new onset diabetes mellitus5 and even patient has a normal blood glucose level6. Although the pathogenesis of diabetes related chorea is not fully understood, some theories

suggested thalamic disinhibition from depletion of inhibitory neurotransmitters, diabetic vasculopathy with consequent vascular insufficiency of the striatum, acute basal ganglia dysfunction secondary to hyperglycemia, hyperosmolarity, hyperviscosity, petechial hemorrhage or inflammatory processes7-10. Hyperdense putamen and/or caudate nucleus is typical CT finding. The most commonly described MRI finding is high signal intensity in basal ganglia on

T1-weighted11. The mainstay of treatment is aggressive glycemic control with a good prognosis, although several case reports have documented hemichorea can occur a few weeks after the blood glucose levels have been controlled.

Reference:

1. Dewey RB Jr, Jankovic J. Hemiballism-hemichorea: clinical and pharmacologic findings in 21 patients. Arch Neurol 1989;46:862–867

2. Padmanabhan S, Zagami AS, Poynten AM: A case of hemichorea-hemiballismus due to nonketotic hyperglycemia. Diabetes Care, 2013; 36(4): e55–e56

3. Oh SH, Lee KY, Im JH, Lee MS. 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. J Neurol Sci Aug 15 2002;200(1–2):57– 62.

4. Lee SH, Shin JA, Kim JH, Son JW, Lee KW, Ko SH, et al. Chorea-ballism associated with nonketotic hyperglycaemia or diabetic ketoacidosis: characteristics of 25 patients in Korea. Diabetes Res Clin Pract Aug 2011;93(2):e80–3.

5. Ifergane G, Masalha R, Herishanu YO. Transient hemichorea/hemiballismus associat-ed with new onset hyperglycemia. Can J Neurol Sci Nov 2001;28(4):365–8.

6. Jorge Bizet, Chad J. Cooper et al. Chorea, Hyperglycemia, Basal Ganglia Syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation. Am J Case Rep, 2014; 15: 143-146

7. Guisado R, Arieff AI. Neurological manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism May 1975;24(5):665–79.

8. Rector Jr WG, Herlong HF, Moses III H. Nonketotic hyperglycemia appearing as choreoathetosis or ballism. Arch Intern Med Jan 1982;142(1):154–5.

9. AbeY,YamamotoT, Soeda T, KumagaiT,TannoY,Kubo J,et al.Diabeticstriataldisease: clinical presentation, neuroimaging,and pathology. Intern Med 2009;48(13):1135–41.

10. Wang JH, Wu T, Deng BQ, Zhang YW, Zhang P, Wang ZK, et al. Hemichorea-hemiballismus associated with nonketotic hyperglycemia: a possible role of inflam-mation. J Neurol Sci Sep 15, 2009;284(1-2):198–202

11. Barry G. Hansford, Dara Albert, Edward Yang, Classic neuroimaging findings of nonketotic hyperglycemia on computed tomography and magnetic resonance imaging with absence of typical movement disorder symptoms (hemichorea-hemiballism). Radiology Case. 2013 Aug; 7(8):1-9

Figure1 Bain CT showed faint hyperattenuation of the entire right basal

gangion which is easily confused with

intracranial hemorrhage

Figure2 Brain MRI after admission showed right basal ganglion

T1-hyperintensity with neuronal loss,

suggestive of chorea associated with non-ketotic hyperglycemia

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