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

Ai Wain Yong,Zoe Morris,Kirsten Shuler,Colin Smith,Joanna Wardlaw

doi:10.1186/1471-2377-12-139

Ai Wain Yong, Zoe Morris + Show 3 more

Open Access

https://doi.org/10.1186/1471-2377-12-139

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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.

Highlights

Acute 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 review the literature to identify patterns of imaging abnormalities, the relationship with neurological findings and the depth and duration of hypoglycaemia and determine how often hypoglycaemia might mimic stroke on imaging, and present two cases of computed tomography (CT) abnormality in acute symptomatic hypoglycaemia, one of which was initially misdiagnosed as ischaemic stroke, clinically and radiologically
New cases Our two new cases were both hospital inpatients recovering from hip replacement operations following traumatic fractured neck of femur

Summary

Introduction

Acute 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. The time course, extent, cortical versus subcortical involvement and relationship of imaging changes to depth or duration of hypoglycaemia and symptoms are lacking, with considerable scope for misdiagnosis. We systematically review the literature to identify patterns of imaging abnormalities, the relationship with neurological findings and the depth and duration of hypoglycaemia and determine how often hypoglycaemia might mimic stroke on imaging, and present two cases of CT abnormality in acute symptomatic hypoglycaemia, one of which was initially misdiagnosed as ischaemic stroke, clinically and radiologically

Methods

Results

Conclusion