Acute symptomatic hypoglycaemia mimicking ischaemic stroke on imaging: a systemic review

Abstract

BackgroundAcute symptomatic hypoglycaemia is a differential diagnosis in patients presenting with stroke-like neurological impairment, but few textbooks describe the full brain imaging appearances. We systematically reviewed the literature to identify how often hypoglycaemia may mimic ischaemic stroke on imaging, common patterns and relationships with hypoglycaemia severity, duration, clinical outcome and add two new cases.MethodsWe searched EMBASE and Medline databases for papers reporting imaging in adults with symptomatic hypoglycaemia. We analysed the clinical presentation, outcome, brain imaging findings, duration and severity of hypoglycaemia, time course of lesion appearance, including two new cases.ResultsWe found 42 papers describing computed tomography or magnetic resonance imaging in 65 patients, plus our two cases with symptomatic hypoglycaemia. Imaging abnormalities on computed tomography and magnetic resonance were uni or bilateral, cortical or sub-cortical. Thirteen (20%) mimicked cortical or lacunar stroke. Acute lesions had restricted diffusion on magnetic resonance or low attenuation on computed tomography, plus swelling; older lesions showed focal atrophy or disappeared, as with ischaemic stroke. The association between the depth or duration of hypoglycaemia, the severity or extent of neurological deficit, and the imaging abnormalities, was weak.ConclusionImaging abnormalities in patients with hypoglycaemia are uncommon but very variable, weakly associated with neurological deficit, and about a fifth mimic acute ischaemic stroke. Blood glucose testing should be routine in all patients with acute neurological impairment and hypoglycaemia should be included in the differential diagnosis of imaging appearances in patients presenting with acute stroke.

Neurofibromatosis 1-associated panhypopituitarism presenting as hypoglycaemic seizures and stroke-like symptoms

“…While the typical MRI finding in hypoglycaemic encephalopathy is bilateral symmetrical grey and white matter involvement, also reported is restricted diffusion in a focal or unilateral cortical and adjacent subcortical distribution, as seen in our patient 21 22. The likelihood that the cortical injury in our case was secondary to hypoglycaemia was further supported by the fact that the neuroimaging abnormalities did not conform to a specific vascular distribution, as would be expected with vascular compromise, but rather occurred in overlapping and multiple vascular territories.…”

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

“…In an imaging-based meta-analysis, ≈20% of hypoglycemic attacks have restricted diffusion on imaging, causing further conflation of ischemic stroke and hypoglycemia. 321 However, it rarely produces stroke-like deficits in the absence of other more typical symptoms such as altered consciousness, seizures, and diaphoresis. Prior studies suggest that mimics resulting from hypoglycemia occurred in <1% of suspected stroke presentations.…”

Hyperperfusion in DWI Abnormality in a Patient with Acute Symptomatic Hypoglycemic Encephalopathy

“…This heterogeneity of hemodynamic response to hypoglycemia may be ascribed from different local energy demand, different concentration of neurotransmitters such as glutamate or vascular structural characteristics (pial arterioles versus perforators). In the previous literature, the patients with ASHE had favorable clinical outcome when the DWI abnormalities confined to the focal WM area of CST like as our case (1,(4)(5)(6). Although this is a single-case experience, localized hyperperfusion in ASHE may mean preservation of compensatory function of CBF control, and it may be associated with good prognosis.…”

“…The diagnosis of acute symptomatic hypoglycemic encephalopathy (ASHE) is usually evident, and diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) map can show early cortical or subcortical abnormalities (1). However, the perfusion change in ASHE is not well known.…”