Hypoglycemic Hemiparesis Masquerading As Ischemic Stroke: When Guideline Fails

Author(s): Dhruvkumar M. Patel, Mukundkumar V. Patel*, Jayanti K. Gurumukhani, Maitri M. Patel, Himal J. Mahadevia, Ritesh A. Gajjar

Journal Name: Current Drug Therapy

Volume 15 , Issue 4 , 2020


Become EABM
Become Reviewer
Call for Editor

Graphical Abstract:


Abstract:

Background: Hypoglycemia may rarely present as hemiparesis and sometimes, it is difficult to differentiate from ischemic stroke. When Random Blood Sugar (RBS) value is between 50 and 70 mg% in patients presenting with focal neurological deficit, no guideline exists to consider the possibility of hypoglycemia before initiating thrombolytic therapy.

Clinical Case: A 58-year-old male, with preexisting illness of diabetes and hypertension diabetes and hypertension, was brought to the emergency room with acute onset of right hemiparesis and dysarthria of 90 minutes duration. His NIHSS Score was 9, blood pressure was 150/90 mm of Hg and RBS was 79 mg% on admission. His CT scan brain was normal and was considered for thrombolysis. The resident doctor was not aware of previous sugar repeated RBS before thrombolysis, which was surprisingly 60 mg% 60 minutes after the first RBS. Even though he was a candidate for thrombolysis, intravenous 25% dextrose was administered considering the possibility of hypoglycemia. He made a complete recovery within 20 minutes and thrombolytic therapy was withheld.

In diabetic patients with focal neurological deficit and RBS less than 80 mg% on admission, RBS should be rechecked and in appropriate cases, should be challenged with IV dextrose considering the possibility of hypoglycemia before commencing thrombolytic therapy.

Keywords: Hypoglycemia, hemiparesis, ischemic stroke, thrombolysis, stroke thrombolysis guidelines, diabetes.

[1]
Agrawal N, Jamshed N, Aggarwal P, Ekka M. Severe hypoglycemia masquerading as cerebellar stroke. J Family Med Prim Care 2014; 3(4): 440-2.
[http://dx.doi.org/10.4103/2249-4863.148144] [PMID: 25657961]
[2]
Ohshita T, Imamura E, Nomura E, Wakabayashi S, Kajikawa H, Matsumoto M. Hypoglycemia with focal neurological signs as stroke mimic: Clinical and neuroradiological characteristics. J Neurol Sci 2015; 353(1-2): 98-101.
[http://dx.doi.org/10.1016/j.jns.2015.04.015] [PMID: 25912175]
[3]
Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: A report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 2013; 36(5): 1384-95.
[http://dx.doi.org/10.2337/dc12-2480] [PMID: 23589542]
[4]
Hafez S, Coucha M, Bruno A, Fagan SC, Ergul A. Hyperglycemia, acute ischemic stroke, and thrombolytic therapy. Transl Stroke Res 2014; 5(4): 442-53.
[http://dx.doi.org/10.1007/s12975-014-0336-z] [PMID: 24619488]
[5]
Johnston KC, Hall CE, Kissela BM, Bleck TP, Conaway MR. GRASP Investigators. Glucose Regulation in Acute Stroke Patients (GRASP) trial: a randomized pilot trial. Stroke 2009; 40(12): 3804-9.
[http://dx.doi.org/10.1161/STROKEAHA.109.561498] [PMID: 19834016]
[6]
Adams HP Jr, Adams RJ, Brott T, et al. Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke. Stroke 2003; 34: 1056-83.
[http://dx.doi.org/10.1161/01.STR.0000064841.47697.22] [PMID: 12677087]
[7]
Adams HP Jr, del Zoppo G, Alberts MJ, et al. American heart association; american stroke association stroke council; clinical cardiology council; cardiovascular radiology and intervention council; atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups. Guidelines for the early management of adults with ischemic stroke. Stroke 2007; 38(5): 1655-711.
[http://dx.doi.org/10.1161/STROKEAHA.107.181486] [PMID: 17431204]
[8]
Hypoglycemia - low blood glucose - american diabetes association. www.diabetes.org2019.
[9]
Tsai SH, Lin YY, Hsu CW, Cheng CS, Chu DM. Hypoglycemia revisited in the acute care setting. Yonsei Med J 2011; 52(6): 898-908.
[http://dx.doi.org/10.3349/ymj.2011.52.6.898] [PMID: 22028152]
[10]
Yoshino T, Meguro S, Soeda Y, Itoh A, Kawai T, Itoh H. A case of hypoglycemic hemiparesis and literature review. Ups J Med Sci 2012; 117(3): 347-51.
[http://dx.doi.org/10.3109/03009734.2011.652748] [PMID: 22247979]
[11]
Kirresh O, Kamara A, Samadian S. Hypoglycaemic haemiparesis. BMJ Case Rep 2013.2013bcr2013008893.
[http://dx.doi.org/10.1136/bcr-2013-008893] [PMID: 24130203]
[12]
Rostami E. Glucose and the injured brain-monitored in the neurointensive care unit. Front Neurol 2014; 5: 91.
[http://dx.doi.org/10.3389/fneur.2014.00091] [PMID: 24936196]
[13]
Hoeldtke RD, Boden G. Epinephrine secretion, hypoglycemia unawareness, and diabetic autonomic neuropathy. Ann Intern Med 1994; 120(6): 512-7.
[http://dx.doi.org/10.7326/0003-4819-120-6-199403150-00011] [PMID: 8311375]
[14]
Meyer C, Grossmann R, Mitrakou A, et al. Effects of autonomic neuropathy on counterregulation and awareness of hypoglycemia in type 1 diabetic patients. Diabetes Care 1998; 21(11): 1960-6.
[http://dx.doi.org/10.2337/diacare.21.11.1960] [PMID: 9802751]
[15]
Martín-Timón I, Del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawareness and implications in diabetic patients. World J Diabetes 2015; 6(7): 912-26.
[http://dx.doi.org/10.4239/wjd.v6.i7.912] [PMID: 26185599]
[16]
Klonoff DC. Point-of-care blood glucose meter accuracy in the hospital setting. Diabetes Spectr 2014; 27(3): 174-9.
[http://dx.doi.org/10.2337/diaspect.27.3.174] [PMID: 26246776]
[17]
Rebel A, Rice MA, Fahy BG. Accuracy of point-of-care glucose measurements. J Diabetes Sci Technol 2012; 6(2): 396-411.
[http://dx.doi.org/10.1177/193229681200600228] [PMID: 22538154]
[18]
Heinemann L, Lodwig V, Freckmann G. Accuracy in blood glucose measurement: What will a tightening of requirements yield? J Diabetes Sci Technol 2012; 6(2): 435-43.
[http://dx.doi.org/10.1177/193229681200600232] [PMID: 22538158]
[19]
Spanakis EK, Cryer PE, Davis SN. Hypoglycemia during therapy of diabetes 2000.https://www.ncbi.nlm.nih.gov/books/NBK279100


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 15
ISSUE: 4
Year: 2020
Published on: 27 December, 2019
Page: [420 - 422]
Pages: 3
DOI: 10.2174/1574885515666191227155624
Price: $65

Article Metrics

PDF: 25
HTML: 1