Unilateral Basal Ganglia CT Abnormality in Hyperosmolar Hyperglycemic Nonketotic State

Abstract

          Hyperosmolar hyperglycemic nonketotic state (HHNS) is a complication in diabetes mellitus patient that may clinically presents as hemichorea-hemiballism especially in elderly Asian patient. Abnormalities of basal ganglia on CT were being associated with new onset chorea that was most often reported among diabetic patient with HHNS. CT exhibited high attenuation at basal ganglia which appeared similar to that of hemorrhage or calcifications. However CT findings in HHNS were hyperdense lesion at basal ganglia without surrounding mass effect or edema. Involuntary movement in patient of HHNS is treatable and has good prognosis if early diagnosis is established and glycemia is controlled. Imaging either CT or MRI is helpful for the diagnosis.

           A 60-year-old Thai man with an underlying DM type II presented with an involuntary movement of the right upper extremity for 3 days. He was clinically diagnosed as having stroke. The NCCT showed homogeneous high attenuation at left caudate and lentiform nuclei. The laboratory tests revealed blood sugar 715 mg/dL, HbA1c 18.62 %, BUN 43 mg/dL, creatinine 1.7 mg/dL, Na 124 mmol/L. The serum osmolarity from calculation was 303.08 mosm/kg. The clinical presentation, CT findings and laboratory results were consistent with HHNS. He was treated with blood sugar control with intensive insulin treatment and hydration. One month later CT showed completely resolved high attenuation at left caudate and lentiform nuclei accompanied by the slow regression of the involuntary movement.