Case Diagnosis: Persistent Hemichorea-Hemiballismus Induced by Non-Ketotic Hyperglycemia and Hemorrhagic Strokes
Case Description: 63-year-old female with a past medical history of hypertension and type 2 diabetes presented with profound right sided hemichorea-hemiballismus. She was admitted two months prior for hemichorea-hemiballismus induced by non-ketotic hyperglycemia and hemorrhagic stroke. Initially, these movements were limited to the right shoulder; however progressed to involve the entirety of the right upper limb, lower limb and jaw. MRI on prior admission showed a hyperintense signal in the left caudate and lentiform nucleus, subacute right cerebellar hemorrhage and multiple remote microhemorrhages in the basal ganglia, thalamocapsular region and cerebral hemispheres. This admission, MRI revealed a hyperintensity of the left caudate head and lentiform nucleus, more prominent than on prior admission. Throughout hospitalization, glucose levels were adequately controlled and HgbA1C improved from 15 to 10 in less than two months. Symptoms failed to completely resolve with haloperidol, diazepam, quetiapine and tetrabenazine. The patient was subsequently transferred to an acute rehabilitation unit.
Discussions: Hemichorea-hemiballismus is a rare hyperkinetic, irregular, wide amplitude movement disorder of the limbs. Strokes followed by non-ketotic hyperglycemia represent the most common etiologies of this condition. While hyperglycemic induced hemichorea-hemiballismus is generally benign and resolves with adequate glycemic control, recovery time after stroke is often more variable and dependent on the nature and location of the lesion. Anti-dopaminergic medications are considered effective first-line agents for symptomatic relief. This patient’s symptoms were surprisingly refractory to both anti-dopaminergic medications and improved glucose regulation. This case uniquely allows the study of recovery time and prognosis in hemichorea-hemiballismus when induced by both non-ketotic hyperglycemia and stroke.
Conclusions: Though hemichorea-hemiballismus induced by non-ketotic hyperglycemia generally resolves with adequate glycemic control, concomitant extensive cerebrovascular disease may impede its recovery and worsen the prognosis.