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

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Presentation transcript:

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

Imaging A B Fernandes, et al © 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