Abstract

BACKGROUND: The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced "excitotoxic injury" of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage.

CASE PRESENTATION: A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions.

CONCLUSIONS: In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different.

Original languageEnglish
Pages (from-to)11
JournalBMC Medical Imaging
Volume19
Issue number1
DOIs
Publication statusPublished - Jan 24 2019

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Brain Diseases
Hypoglycemic Agents
Stroke
Magnetic Resonance Imaging
Axons
Infarction
Edema
Leukoencephalopathies
Internal Capsule
Glucose
Pyramidal Tracts
Sweating
Unconsciousness
Facial Paralysis
Poisons
Wounds and Injuries
Amyotrophic Lateral Sclerosis
Appetite
Myelin Sheath
Brain Ischemia

Keywords

  • Aged
  • Brain Diseases/diagnostic imaging
  • Brain Ischemia/pathology
  • Diagnosis, Differential
  • Female
  • Humans
  • Hypoglycemia/complications
  • Insulin/therapeutic use
  • Magnetic Resonance Imaging/methods
  • Pyramidal Tracts/diagnostic imaging
  • Stroke/pathology
  • Treatment Outcome

Cite this

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title = "Hypoglycemic encephalopathy mimicking acute ischemic stroke in clinical presentation and magnetic resonance imaging: a case report",
abstract = "BACKGROUND: The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced {"}excitotoxic injury{"} of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage.CASE PRESENTATION: A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions.CONCLUSIONS: In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different.",
keywords = "Aged, Brain Diseases/diagnostic imaging, Brain Ischemia/pathology, Diagnosis, Differential, Female, Humans, Hypoglycemia/complications, Insulin/therapeutic use, Magnetic Resonance Imaging/methods, Pyramidal Tracts/diagnostic imaging, Stroke/pathology, Treatment Outcome",
author = "Kai-I Chuang and Hsieh, {Kevin Li-Chun} and Cheng-Yu Chen",
year = "2019",
month = "1",
day = "24",
doi = "10.1186/s12880-019-0310-z",
language = "English",
volume = "19",
pages = "11",
journal = "BMC Medical Imaging",
issn = "1471-2342",
publisher = "BioMed Central",
number = "1",

}

TY - JOUR

T1 - Hypoglycemic encephalopathy mimicking acute ischemic stroke in clinical presentation and magnetic resonance imaging

T2 - a case report

AU - Chuang, Kai-I

AU - Hsieh, Kevin Li-Chun

AU - Chen, Cheng-Yu

PY - 2019/1/24

Y1 - 2019/1/24

N2 - BACKGROUND: The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced "excitotoxic injury" of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage.CASE PRESENTATION: A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions.CONCLUSIONS: In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different.

AB - BACKGROUND: The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced "excitotoxic injury" of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage.CASE PRESENTATION: A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions.CONCLUSIONS: In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different.

KW - Aged

KW - Brain Diseases/diagnostic imaging

KW - Brain Ischemia/pathology

KW - Diagnosis, Differential

KW - Female

KW - Humans

KW - Hypoglycemia/complications

KW - Insulin/therapeutic use

KW - Magnetic Resonance Imaging/methods

KW - Pyramidal Tracts/diagnostic imaging

KW - Stroke/pathology

KW - Treatment Outcome

U2 - 10.1186/s12880-019-0310-z

DO - 10.1186/s12880-019-0310-z

M3 - Article

C2 - 30678650

VL - 19

SP - 11

JO - BMC Medical Imaging

JF - BMC Medical Imaging

SN - 1471-2342

IS - 1

ER -