Hypoglycaemic hemiplegia: a repeat SPECT study

Hemiparesis With Hypoglycemia in a Child With Hypopituitarism Involving LHX4 Gene Deletion

We report a case of a 17-month-old boy with developmental delay who presented with acute-onset right-sided hemiparesis and hypoglycemia. Severe hypotension developed during his sedation for MRI and magnetic resonance angiography. Imaging revealed a hypoplastic pituitary gland within a shallow sella turcica and findings suggestive of moyamoya syndrome. Hemiparesis resolved 5 hours after correction of hypoglycemia with dextrose infusion, and severe hypotension improved with crystalloid fluids and vasopressors. Magnetic resonance angiography repeated 24 hours later revealed resolution of the vascular finding. Additional biochemical testing was consistent with hypopituitarism, and genetic evaluation revealed that the patient had a microdeletion including the LHX4 gene, which has been implicated in combined pituitary hormone deficiency type IV. Hypoglycemia frequently presents with autonomic or neuroglycopenic symptoms. However, when hypoglycemia presents with an isolated neurologic deficit like hemiparesis with preservation of alertness, it can be challenging to differentiate a cerebrovascular event from hypoglycemia-induced symptoms, leading to a delay in endocrine evaluation. Hypoglycemic hemiparesis is rare in childhood and is reported in children with diabetes mellitus or hyperinsulinism. This case expands the clinical spectrum of hemiparesis as a presenting sign of hypoglycemia in growth hormone and adrenocorticotropic hormone/cortisol deficiencies.

Multi-modal brain imaging showing brain damage to the orbitofrontal cortex and left hemisphere, in a case of prolonged hypoglycemia-induced transient hemiplegia followed by persistent encephalopathy

A 21-year-old left-handed male patient was admitted with a 19-h history of coma after substantial insulin injection for suicide attempt. Although the patient recovered from coma 3 days after injury, he experienced transient hemiplegia followed by permanent brain damage. Electroencephalogram (EEG), brain magnetic resonance imaging (MRI), and brain single-photon emission computed tomography (SPECT) identified the localization of this dysfunction, but consistency between clinical symptoms and brain images changed depending on the course of treatment. Transient hemiplegia corresponded to abnormal waveforms on EEG and decreased cerebral blood flow on SPECT, whereas persistent dysfunctions corresponded to abnormal brain regions on MRI and SPECT.

A case of hypoglycemic hemiparesis and literature review

An 89-year-old man with diabetes treated with metformin 500 mg/day and glimepiride 4 mg/day was hospitalized because of hypoglycemic right hemiparesis and dysarthria (casual glucose value 1.8 mmol/L), which resolved quickly following administration of 40 mL of 40% dextrose. Hemiparesis is a rare symptom (4.2%) of hypoglycemia. There are about 200 case reports of hypoglycemic hemiparesis. The average glucose level at which hemiparesis developed was 1.8 mmol/L. Right-sided hemiparesis predominated (R 66%; L 34%). On imaging studies, abnormal findings were frequently observed in the internal capsule or splenium of the corpus callosum. The mechanism of hemiparesis is not fully understood. The existence of cases in which hypoglycemia cannot be distinguished from stroke on imaging studies suggests the importance of measurement of the blood glucose level when the symptoms of stroke are first recognized.

Hypoglycemic hemiplegia: insulinoma masquerading as stroke

We report a patient with recurrent episodes of hemiplegia caused by hypoglycemia. Investigations revealed an insulinoma, which was surgically removed. After this, the blood glucose level normalized and the patient remained asymptomatic for 9 months. We discuss pathophysiological mechanisms whereby hypoglycemia might cause focal neurological deficit.

Acute brain injury in hypoglycaemia-induced hemiplegia

BACKGROUND

The development of hemiplegia as a result of hypoglycaemia was first described in 1928. However, the mechanism remains unclear.

CASE REPORT

We report a case of a 58-year-old male with diabetes, who developed left hemiplegia during a severe hypoglycaemic event. Results Diffusion-weighted magnetic resonance imaging detected an increased signal intensity in the pons, indicating that the patient's hemiplegia resulted from acute brain injury.

CONCLUSIONS

This report provides evidence that acute brain injury may be a cause of the neurological deficit.

[Diagnostic pitfalls in sulfonylurea-induced neuroglycopenic syndrome with hemiparesis, dysphasia and somnolence]

BACKGROUND

The neuroglycopenic syndrome, which is often due to sulfonylurea-induced hypoglycemia, is frequently overlooked or misinterpretated as cerebral ischemia.

PATIENTS

Two women aged 81 and 83 years, respectively, with type II diabetes treated with sulfonylureas presented with hemiparesis, dysphasia and somnolence. Both, general practitioner and emergency room physician first interpretated the symptoms as clinical signs of stroke without determination of blood glucose. After hours of delay due to unnecessary and expensive examinations including cerebral computed tomography the correct diagnosis of hypoglycemia was finally made. After injection of i.v. glucose the symptomatology was completely reversible.

CONCLUSION

In every case of disturbance of consciousness, acute neurologic deficits and psychiatric abnormalities an immediate blood glucose test should be performed to exclude hypoglycemia.

High incidence of hypoglycemic episodes with neurologic manifestations in children with insulin dependent diabetes mellitus

Hypoglycemia is a serious frequent complication of insulin therapy in type 1 diabetes.

PATIENTS AND METHODS

We surveyed 139 IDDM patients.

RESULTS

Forty-four patients (32%) reported at least one severe hypoglycemic episode. All patients with severe hypoglycemia experienced neurological manifestations. Symptoms included confusion and abnormal behavior, convulsions, coma, transient hemiparesis and one case of permanent hemiparesis. Most episodes occurred at night or during morning hours. 44% of episodes were related to delayed meal or snack, 11% to excess insulin administration and 13% to extra physical activity. HbA1c was significantly lower in patients with severe hypoglycemia compared with diabetic controls (7.33 +/- 1.09% and 9.45 +/- 4.32%, respectively).