Paroxysmal bilateral involuntary movements without striatal imaging abnormalities in hyperglycemia-related metabolic encephalopathy after pancreatic resection: a case report

Background Hyperglycemia-related metabolic encephalopathy is an uncommon but clinically important neurological complication of diabetes. It most frequently presents as hemichorea–hemiballism associated with characteristic striatal abnormalities on neuroimaging. However, atypical presentations without imaging correlates remain underrecognized. Case presentation We report a 72-year-old woman with long-standing type 2 diabetes who developed paroxysmal involuntary movements involving the head, neck, and bilateral upper limbs following pancreatic tumor resection. The episodes were irregular, non-stereotyped, and occurred with preserved consciousness. Brain MRI revealed no acute lesions or characteristic striatal signal changes. Long-term video electroencephalography showed diffuse slow-wave activity without epileptiform discharges, effectively excluding an epileptic origin. Comprehensive cerebrospinal fluid and serological testing ruled out autoimmune and paraneoplastic etiologies. Notably, the patient exhibited marked glucose fluctuations during hospitalization rather than persistent severe hyperglycemia. The involuntary movements gradually resolved following stabilization of blood glucose levels. Conclusions This case expands the clinical spectrum of hyperglycemia-related movement disorders by demonstrating that they may present as paroxysmal, bilateral, and complex involuntary movements without typical imaging abnormalities. Postoperative metabolic instability following pancreatic resection may represent an important precipitating factor. Early recognition of this atypical phenotype is essential to avoid misdiagnosis and unnecessary interventions.