A*******s
发帖数: 9638 | 1 这是一个真实的case， 因为HIPPA， 我做了修改。
64 yrs old female presented with bizzare movement of her left hand. Her
symptoms started about 3 weeks ago, and she could not do anything with her
left hand, had to wear an elbow brace to limit hand movement. Therefore, she
could not even open her pill bottles. She denied any other symptoms, like
pain of arm, paresthesia or weakness. |
A*******s
发帖数: 9638 | 2 PMH: DM, type 2.
Social: No Smoking/ETOH/Drug abuse.
FMH: No history of movement disorder.
ROS：Not remarkable.
PE: VSS: Normal
Except chorea movement and areflexia, all other exams are normal. |
A*******s
发帖数: 9638 | 3 CBC, CMP, HgA1c Pending.
MRI of brain on T1 image shows below. Radiology reads as possible Bleeding. |
A*******s
发帖数: 9638 | 4 Because of the reading, I ordered a CT of brain which is somewhat sensitive to
blood. See below.
Radiology reads as bleeding vs calcification.
Bleeding.
【在 A*******s 的大作中提到】
: CBC, CMP, HgA1c Pending.
: MRI of brain on T1 image shows below. Radiology reads as possible Bleeding.
|
A*******s
发帖数: 9638 | 5 On the next day when she was having CT, the patient was found confused so she was admitted to hospital. Her glucose was 500 with mild acidosis. Apparently, she could not take her DM pills due to the chorea.
What is the diagnosis?
说对的有BZ. |
C*****D
发帖数: 1299 | |
A*******s
发帖数: 9638 | 7 呵呵， 她不养狗， 不养猫， 不吃肉。 不发烧， 不头疼， 虫子可能性不大。
【在 C*****D 的大作中提到】
: 还是脑子那东东闹腾。不会是虫子吧
|
a*********d
发帖数: 2763 | 8 http://www.ajnr.org/content/25/6/975.full.pdf
对不起我又放狗搜了，看到一个跟我专业有关但是不知道跟你这个case有没有关系，
UCSF的一个case report
Summary: A 75-year-old Asian man presented with two episodes
of chorea associated with nonketotic hyperglycemia. His
chorea rapidly resolved after restitution of a normal serum
glucose level, although an MR image obtained at the time of
acute symptoms demonstrated high signal intensity on T1-
weighted images, low signal intensity on T2-weighted images,
and restricted diffusion, all involving the left putamen. A CT
scan obtained 1 month later demonstrated faint hyperattenuation
of the involved putamen. The reported pathophysiologic
considerations for these imaging features are reviewed, and
an original explanation is proposed. |
A*******s
发帖数: 9638 | 9 This is so called "Chances favor the prepared mind."
Congratulations! You've got it.
Nonketotic hyperglycemia induced chorea. It is an unilateral presentation,
a classic case.
A huge mistake if it is taken as intracranial hemorrhage. The MRI/CT could
be misleading.
【在 a*********d 的大作中提到】
: http://www.ajnr.org/content/25/6/975.full.pdf
: 对不起我又放狗搜了，看到一个跟我专业有关但是不知道跟你这个case有没有关系，
: UCSF的一个case report
: Summary: A 75-year-old Asian man presented with two episodes
: of chorea associated with nonketotic hyperglycemia. His
: chorea rapidly resolved after restitution of a normal serum
: glucose level, although an MR image obtained at the time of
: acute symptoms demonstrated high signal intensity on T1-
: weighted images, low signal intensity on T2-weighted images,
: and restricted diffusion, all involving the left putamen. A CT
|
y******a
发帖数: 590 | 10 为啥会有high T1 signal呢？血糖降下来她的chorea好了么？
【在 A*******s 的大作中提到】
: This is so called "Chances favor the prepared mind."
: Congratulations! You've got it.
: Nonketotic hyperglycemia induced chorea. It is an unilateral presentation,
: a classic case.
: A huge mistake if it is taken as intracranial hemorrhage. The MRI/CT could
: be misleading.
|
|
|
S**********e
发帖数: 1325 | 11 attending前辈负责答了题，艾嘉嘉你给pre-resident级别的童鞋做做teaching好么? |
a*********d
发帖数: 2763 | 12 man, blind cat caught dead rat! faint!
【在 A*******s 的大作中提到】
: This is so called "Chances favor the prepared mind."
: Congratulations! You've got it.
: Nonketotic hyperglycemia induced chorea. It is an unilateral presentation,
: a classic case.
: A huge mistake if it is taken as intracranial hemorrhage. The MRI/CT could
: be misleading.
|
P******t
发帖数: 1717 | 13 糖尿病引起的血管变性，导致基底神经节区域出血？ |
A*******s
发帖数: 9638 | 14 T1 hyperintensity 可以在很多情况下见到， metabolic因素是除了出血最常见的。
关键是这个case是单侧的， 所以很容易被认为是出血。 metabolic一般是bilateral。
这个病人还在医院， 不过根据literature， 症状应该随着MRI正常而正常了， 当然是
在血糖控制好了以后。
【在 y******a 的大作中提到】
: 为啥会有high T1 signal呢？血糖降下来她的chorea好了么？
|
A*******s
发帖数: 9638 | 15 大家提问， 有问必答。
【在 S**********e 的大作中提到】
: attending前辈负责答了题，艾嘉嘉你给pre-resident级别的童鞋做做teaching好么?
|
A*******s
发帖数: 9638 | 16 我觉得一个好医生与坏医生的区别是motivation。 同样一个case，有的医生头痛医头
，脚痛医脚， 高血糖因为糖尿病引起， 就给insulin； chorea是因为大脑的出血，
给haldol或者ativan控制症状就行了。 可是如果像你一样去Google一下， 答案不难找
到。
瞎猫至少要有食欲，到处嗅闻， 才能碰到死耗子。 ：）
【在 a*********d 的大作中提到】
: man, blind cat caught dead rat! faint!
|
A*******s
发帖数: 9638 | 17 这个病变不是出血， 而是hyperglycemia引起的metabolic derangement在basal
ganglion造成MRI/CT影像的改变。 当然这样的改变是病理性的， 可能与osmolarity有
关。
【在 P******t 的大作中提到】
: 糖尿病引起的血管变性，导致基底神经节区域出血？
|
S**********e
发帖数: 1325 | 18 学习了！
鼓励同样学习了的童鞋们拿包子砸下a++
砸晕了他，下回他还能写，嘿嘿
【在 A*******s 的大作中提到】
: 这个病变不是出血， 而是hyperglycemia引起的metabolic derangement在basal
: ganglion造成MRI/CT影像的改变。 当然这样的改变是病理性的， 可能与osmolarity有
: 关。
|
m********4
发帖数: 607 | 19 I've learned that there are three things which can cause hyperdensity (white
) on CT--- bone, calcification, blood. If it isn't blood, what is it?
The location of hyperdensity in this case is close to thalamus, basal
ganglia, and substantia nigra.
Over-activity of the neurotransmitter dopamine can induce chorea-like
movement. Substantia nigra pars compacta has dopaminergic neurons.
It will be very interesting if the hyperdensity disappears soon after the
glucose level is well controlled.
【在 A*******s 的大作中提到】
: T1 hyperintensity 可以在很多情况下见到， metabolic因素是除了出血最常见的。
: 关键是这个case是单侧的， 所以很容易被认为是出血。 metabolic一般是bilateral。
: 这个病人还在医院， 不过根据literature， 症状应该随着MRI正常而正常了， 当然是
: 在血糖控制好了以后。
|
k********n
发帖数: 756 | 20 the silhouette of T1 signal does not support bleeding at all. The
radiologist should retake his training.
what the T2 show? |
|
|
A*******s
发帖数: 9638 | 21 CT hyperdensity could at least include the following:
Blood (hematoma or clots)
Calcified soft-tissue
Bone
Densely collagenized tissue (dura, meningioma)
Hypercellularity (inflammatory and neoplastic)
Small round blue-cell tumors (lymphoma, PNET - medullo, pineoblastoma,
retinoblastoma)
and metabolic changes like in this case.
white
【在 m********4 的大作中提到】
: I've learned that there are three things which can cause hyperdensity (white
: ) on CT--- bone, calcification, blood. If it isn't blood, what is it?
: The location of hyperdensity in this case is close to thalamus, basal
: ganglia, and substantia nigra.
: Over-activity of the neurotransmitter dopamine can induce chorea-like
: movement. Substantia nigra pars compacta has dopaminergic neurons.
: It will be very interesting if the hyperdensity disappears soon after the
: glucose level is well controlled.
|
k********n
发帖数: 756 | 22 the silhouette of T1 signal does not support bleeding at all. The
radiologist should retake his training.
what the T2 show? |
A*******s
发帖数: 9638 | 23 T2 is low white. But proton is black. DWI is normal.
【在 k********n 的大作中提到】
: the silhouette of T1 signal does not support bleeding at all. The
: radiologist should retake his training.
: what the T2 show?
|
f*****w
发帖数: 1451 | 24 学习了.
但是我不理解的是这个病人是先出现了chorea,然后导致她无法正常服药,进而导致血糖
升高.
如果是高血糖导致的病变,那么说明在她还正常服药的时候,血糖就没有控制好,是吗? |
A*******s
发帖数: 9638 | 25 是的， 这个病人以前一直有noncompliance的问题。 有了chorea后， 她就把chorea当
挡箭牌了。
【在 f*****w 的大作中提到】
: 学习了.
: 但是我不理解的是这个病人是先出现了chorea,然后导致她无法正常服药,进而导致血糖
: 升高.
: 如果是高血糖导致的病变,那么说明在她还正常服药的时候,血糖就没有控制好,是吗?
|
g*2
发帖数: 658 | 26 那就不象出血了
low white 应该也算hyperintense
T1 hyperintense, plus T2+FLAIR hypointense -> bleeding.
DW images hyperintense -> bleeding
【在 A*******s 的大作中提到】
: T2 is low white. But proton is black. DWI is normal.
|
r*****t
发帖数: 53 | 27 Interesting explanation. BTW, didn't know that you're a neurologist.....
【在 A*******s 的大作中提到】
: 是的， 这个病人以前一直有noncompliance的问题。 有了chorea后， 她就把chorea当
: 挡箭牌了。
|
r*********n
发帖数: 949 | 28 Hyperglycemia related chorea, the pathology of the signal change is unknown.
. different literatures with different results. Saw two similar cases in the
past. |
l******u
发帖数: 152 | 29 哈哈，这么巧！
我有个非常类似的病例，写给ACP参加abstract比赛，居然给拒了，嗨！！！看来我写
的太差，浪费了好好的病例！ |
m********4
发帖数: 607 | 30 Have this patient done CTA and perfusion image?
It is not rare to see a patient with higher glucose level than 550 in
hospital. Last week, we had a STEMI pt with glucose level>550.(pt doesn't
have DM history).
It is common to see pt with DM has all kind of vascular disease.
But, hyperglycemia induced chorea-like movement disorder isn't common.
she
【在 A*******s 的大作中提到】
: 这是一个真实的case， 因为HIPPA， 我做了修改。
: 64 yrs old female presented with bizzare movement of her left hand. Her
: symptoms started about 3 weeks ago, and she could not do anything with her
: left hand, had to wear an elbow brace to limit hand movement. Therefore, she
: could not even open her pill bottles. She denied any other symptoms, like
: pain of arm, paresthesia or weakness.
|
|
|
m*********6
发帖数: 609 | |
A*******s
发帖数: 9638 | 32 Why CTA with perfusion? She did not have a stroke and DWI was negative.
【在 m********4 的大作中提到】
: Have this patient done CTA and perfusion image?
: It is not rare to see a patient with higher glucose level than 550 in
: hospital. Last week, we had a STEMI pt with glucose level>550.(pt doesn't
: have DM history).
: It is common to see pt with DM has all kind of vascular disease.
: But, hyperglycemia induced chorea-like movement disorder isn't common.
:
: she
|
m********4
发帖数: 607 | 33 What will happen if stenosis, but not occlusion, exists on the deep branch
of MCA?
angina vs MI is different.
Trop doesn't have 100% sensitivity or 100% specificity.
Medicine is science. Medical diagnosis needs evidence to r/o or r/i, right?
【在 A*******s 的大作中提到】
: Why CTA with perfusion? She did not have a stroke and DWI was negative.
|
A*******s
发帖数: 9638 | 34 MCA stenosis: ASA
MCA occlusion: ASA
MCA wide open but multiple risk factors for stroke: ASA
CTA with perfusion is not going to change anything.
Do you know how much CTA with perfusion costs? Save the money for the most
needed.
【在 m********4 的大作中提到】
: What will happen if stenosis, but not occlusion, exists on the deep branch
: of MCA?
: angina vs MI is different.
: Trop doesn't have 100% sensitivity or 100% specificity.
: Medicine is science. Medical diagnosis needs evidence to r/o or r/i, right?
|
z****k
发帖数: 95 | |
b******a
发帖数: 704 | 36 学习了。 很有趣。 谢谢大家。
那些METABOLIC的变化能引起影像的变化呢？ |
A*******s
发帖数: 9638 | 37 Glucose, Calcium, Iron, etc.
【在 b******a 的大作中提到】
: 学习了。 很有趣。 谢谢大家。
: 那些METABOLIC的变化能引起影像的变化呢？
|
