Description

A 78-year-old Taiwanese woman presented with polyuria. She denied history of type 2 diabetes mellitus, or cerebral vascular disease. In examinations, the skin turgors were dry. The laboratory data revealed that serum glucose level was 45.34 mmol per litre, sodium level was 133 mmol per litre, haemoglobin A1c was 13.5% and serum osmolarity was 308 mmol per litre. The serum ketone body was negative. However, after 1 week, a sudden onset of involuntary dyskinesia over left side of limbs (video 1) occurred. The serum sodium level was 136 mmol per litre, and serum glucose levels was 10.3 mmol per litre. She had no other abnormality which could explain the movement disorder. The CT of brain showed bilateral high signals in striatum, (figure 1) and the MR of brain with gadolinium enhanced T1-weighted images displayed bilateral local high-signals of globus pallidus (figure 2 with red arrow). The symptoms continued but ameliorated after oral risperidol for 2 weeks. Hemiballism is a reversible but rare disorder primarily affecting older Asian diabetic patients during hyperglycaemic crises.1 Although traditional hemiballism related to hyperglycaemic states correlates with a contralateral hypertensity T1-weighted MR image over striatum, bilateral involvement might subacutely develop beyond the episode of hyperglycaemia.2 Rapid correction of diabetic ketoacidosis may also cause the delayed hemiballism and central pontine myelinolysis.3 Recently, a reversible ischaemic insult over striatum potentiated by hyperglycaemia could be detected by spectroscopy. Early detection of ischaemic insults of stratium are keys to prevent long-term damage after episodes of hyperglycaemia.

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Figure 1

The CT of brain showed bilateral high signals in striatum

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Figure 2

The gadolinium enhanced T1-weighted images of brain MR displayed bilateral localised high-signals over globus pallidus (red arrow).