Facial twitching: calcium or concussion conundrum? Hypocalcaemia in a young American football player masking an internal carotid artery dissection

Abstract

A 30-year-old male American football player presented to the acute medical unit with left-hand and hemifacial spasms. History and examination revealed hemifacial spasms in keeping with seizure-like activity possibly due to symptomatic hypocalcaemia. Subsequent investigations revealed an adjusted calcium of 1.87 mmol/L and, hence, he was managed with intravenous calcium replacement. He presented two further times in a 1-month period, with subjective limb weakness, despite normal adjusted calcium. During his third admission, he developed slurred speech and a marked facial droop, with absence of power in the right upper limb. Imaging revealed acute and old infarctions in the left middle cerebral artery territory and appearances consistent with left internal carotid artery dissection. This presentation of arterial stroke is atypical but with potentially grave consequences if missed. There is limited literature on the presentation of hemifacial spasm, and its association with ischaemic or haemorrhagic stroke represents a key learning point.

Stroke and Athletes: A Scoping Review

“…Not all articles cited [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ] in the Table 1 described the vascular mechanism of stroke [ 47 ]. Many strokes, however, were identified as ischaemic in nature (~57%), with 7 cases (17.9%) of vertebral artery dissection, 5 cases (12.8%) of each intracranial artery dissection, cerebral infarction, and subarachnoid hemorrhage, and 11 cases (30.7%) with neck trauma leading to dissection.…”

“…Genetic predispositions can put individuals at a much greater risk for stroke and therefore should be documented for improved identification and education [ 81 ]. Several cases describing undiagnosed or undiscovered genetic abnormalities which subsequently led towards a stroke were identified [ 38 , 45 , 46 , 47 , 52 ] and many were only reported in news-type literature such as newspapers [ 54 ]. Three separate cases of high-level athletes with undiagnosed holes in the heart (i.e., patent foramen ovalem [ 33 , 54 ]; atrial septal defect, [ 53 ] contributed to adverse cardiovascular events).…”

“…Not all articles cited in the Table 1 described the vascular mechanism of stroke [47]. Many strokes, however, were identified as ischaemic in nature (~57%), with 7 cases (17.9%) of vertebral artery dissection, 5 cases (12.8%) of each intracranial artery dissection, cerebral infarction, and subarachnoid hemorrhage, and 11 cases (30.7%) with neck trauma leading to dissection.…”