63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow...

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63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology

Transcript of 63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow...

Page 1: 63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology.

63 year-old woman with subacute parkinsonism

Teaching NeuroImagesNeurology

Resident and Fellow Section

© 2014 American Academy of Neurology

Page 2: 63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology.

Vignette

• A 63 year-old woman with type 2 diabetes mellitus on hemodialysis presented with subacute onset of slurred speech and difficulty walking after one week of inadvertent metformin use.

• On examination, she had a wide-based gait, symmetric upper limb rigidity, bradikynesia and slurred speech.

• Brain CT and MRI revealed a pattern of vasogenic edema in the basal ganglia bilaterally.

• Metformin was interrupted and she recovered after one week of daily hemodialysis.

Fernandes, et al© 2014 American Academy of Neurology

Page 3: 63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology.

ImagingA B

Fernandes, et al© 2014 American Academy of Neurology

Page 4: 63 year-old woman with subacute parkinsonism Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology.

Lentiform fork sign

• Axial noncontrast CT showed bilateral hypodensities in the basal ganglia (Figure 1a).

• Brain MRI revealed a pattern of vasogenic edema with T2/FLAIR hyperintensity in the basal ganglia compatible with the lentiform fork sign(1) (arrows, Figure 1b).

• There was no contrast enhancement and no restriction in diffusion-weighted imaging.

• Basal ganglia pathology has been described on the setting of metabolic acidosis and metformin use in hemodialysis patients, resulting in a parkinsonian syndrome(2).

Fernandes, et al© 2014 American Academy of Neurology


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