Surgical Intervention for Posthyperglycemic Hemiballismus: Illustrative Case and Literature Review

BACKGROUND: Hemiballismus/hemichorea can manifest as a systemic sequala of severe hyperglycemia. This typically resolves with optimal glycemic control supplemented by neuroleptic agents. However, in a subset of patients, this hyperkinetic movement disorder may persist despite maximal medical management. CASES: We present a 70-year-old man with type 2 diabetes mellitus (DM) who presented with 6 months of right-sided hemiballismus/hemichorea that started after a previous episode of nonketotic hyperglycemia. Despite optimal glucose control and the administration of several neuroleptic agents, his symptoms failed to resolve. He underwent left-sided deep brain stimulation (DBS) to the globus pallidus internus (GPi), with subsequent improvement in his hyperkinetic movements. LITERATURE REVIEW: We document 7 cases in the literature of posthyperglycemic chorea-ballism (PHGCB) treated with either pallidal or thalamic DBS or pallidotomy. The procedures were safe and well tolerated, and all patients demonstrated clinical improvement following surgery. CONCLUSION: PHGCB represents a rare but serious complication of DM. There is a subset of patients who fail to respond to maximal medical therapy. Our illustrative case and review demonstrate that these patients may benefit from neurosurgical intervention. Further studies with long-term follow-up are warranted to substantiate the value of surgical approaches for medically refractory diabetic striatopathy.