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Hamid M, Benmoh Y, Bourazza A. Hypoglycemic encephalopathy with extensive brain injuries: A case report. Radiol Case Rep 2023; 18:4495-4498. [PMID: 37868008 PMCID: PMC10589743 DOI: 10.1016/j.radcr.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/24/2023] Open
Abstract
Hypoglycemia is known as a sudden diminution in blood glucose level <50 mg/dL. Hypoglycemic encephalopathy is a metabolic encephalopathy that is usually observed in patients treated for diabetes or chronic alcoholism. Neurological manifestations may range from transient deficits to prolonged coma, depending on the duration and severity of hypoglycemia. Neuroradiological features of hypoglycemia are variable involving the cerebral white and gray matter regions. Acquired metabolic or toxic conditions can cause hypoglycemia-like damage to the cerebral white matter and basal ganglia. Widespread lesions in the brain parenchyma or basal ganglia have a poor prognosis. In this report, we present a patient with widespread brain damage secondary to profound and prolonged hypoglycemia.
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Affiliation(s)
- Mohamed Hamid
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
| | - Youssouf Benmoh
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
| | - Ahmed Bourazza
- Department of Neurology, Mohammed V Military Instruction Hospital, Rabat, Morocco
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2
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Bilateral middle cerebellar peduncle compromise due to hypoglycemic encephalopathy: A case report and literature review. Radiol Case Rep 2022; 17:4599-4602. [PMID: 36193280 PMCID: PMC9525810 DOI: 10.1016/j.radcr.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
Hypoglycemic encephalopathy constitutes a critical presentation of severely diminished glucose levels. We present the case of a 53-year-old male patient with a history of diabetes mellitus with hypoglycemic encephalopathy and MRI findings of bilateral middle cerebellar peduncle lesions. Common findings of hypoglycemic encephalopathy described in the literature consist of bilateral compromise of the cerebral cortex, basal ganglia, hippocampus, and long tracts of white matter. The cerebellum and brainstem are usually not affected. This is the ninth report of cerebellar peduncle compromise with hypoglycemia. As increasing evidence regarding prognosis estimation of lesion distribution arises, we consider it important to report the different cases of rare patterns of compromise.
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Zhang Y, Chen D, Ji Y, Yu W, Mao J. Dynamic magnetic resonance imaging findings in the early stages of neonatal hypoglycemic brain injury. Eur J Pediatr 2022; 181:4167-4174. [PMID: 36166098 DOI: 10.1007/s00431-022-04637-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/11/2022] [Accepted: 09/23/2022] [Indexed: 11/27/2022]
Abstract
UNLABELLED Hypoglycemia is common among neonates and can cause neurological dysfunction. This study aimed to identify the specific time window to perform diffusion-weighted imaging (DWI) for detecting early brain injury in neonatal hypoglycemia and assess the clinical characteristics and neurological outcomes of different patterns of brain injury in neonatal hypoglycemia. We conducted a retrospective analysis of the changes in conventional magnetic resonance imaging (MRI) and DWI at different time points and clinical characteristics in 86 neonates with hypoglycemic brain injury. Among 139 DWI scans, 84 showed injury site hyperintensities within 7 days after hypoglycemia. Thirty-nine scans revealed low DWI and abnormal T1-/T2-weighted imaging signals within 11-23 days after onset, of which 21 showed DWI hyperintensities in the corpus callosum. Abnormal signals were undetected in the second scans of 13 infants within 9-20 days after onset. Vulnerable sites comprised the occipital lobe (98%), splenium of the corpus callosum (60%), and parietal lobe (30%). Compared with focal injury (n = 66), extensive injury (n = 20) had higher involvement of the internal capsule, basal ganglia, and thalamus (P < 0.05); higher incidence of recurrent convulsions, respiratory failure, and coma (P < 0.01); and a higher proportion of death and severe neurodevelopmental impairment (P < 0.05). CONCLUSIONS Neonatal hypoglycemic brain injury was most common in the occipital lobes. Severe clinical symptoms were significantly associated with extensive brain injury involving the internal capsule, basal ganglia, and thalamus, which could be attributed to hypoxia-ischemia and lead to a poor prognosis. WHAT IS KNOWN • There is no clear neurological safe threshold for hypoglycemia in neonates. Studies suggest that symptomatic hypoglycemia can be related to brain injury. WHAT IS NEW • Severe clinical symptoms are significantly associated with extensive brain injury on MRI scans. Extensive brain injuries involving the internal capsule, basal ganglia, and thalamus, which could be due to associated hypoxia-ischemia and lead to a poor prognosis.
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Affiliation(s)
- Yi Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dan Chen
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yalian Ji
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wenting Yu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jian Mao
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.
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Sangare A, Marois C, Perlbarg V, Pyatigorskaya N, Valente M, Zyss J, Borden A, Lambrecq V, Le Guennec L, Sitt J, Weiss N, Rohaut B, Demeret S, Puybasset L, Demoule A, Naccache L. Description and Outcome of Severe Hypoglycemic Encephalopathy in the Intensive Care Unit. Neurocrit Care 2022; 38:365-377. [PMID: 36109449 DOI: 10.1007/s12028-022-01594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disorders of consciousness due to severe hypoglycemia are rare but challenging to treat. The aim of this retrospective cohort study was to describe our multimodal neurological assessment of patients with hypoglycemic encephalopathy hospitalized in the intensive care unit and their neurological outcomes. METHODS Consecutive patients with disorders of consciousness related to hypoglycemia admitted for neuroprognostication from 2010 to 2020 were included. Multimodal neurological assessment included electroencephalography, somatosensory and cognitive event-related potentials, and morphological and quantitative magnetic resonance imaging (MRI) with quantification of fractional anisotropy. Neurological outcomes at 28 days, 3 months, 6 months, 1 year, and 2 years after hypoglycemia were retrieved. RESULTS Twenty patients were included. After 2 years, 75% of patients had died, 5% remained in a permanent vegetative state, 10% were in a minimally conscious state, and 10% were conscious but with severe disabilities (Glasgow Outcome Scale-Extended scores 3 and 4). All patients showed pathologic electroencephalography findings with heterogenous patterns. Morphological brain MRI revealed abnormalities in 95% of patients, with various localizations including cortical atrophy in 65% of patients. When performed, quantitative MRI showed decreased fractional anisotropy affecting widespread white matter tracts in all patients. CONCLUSIONS The overall prognosis of patients with severe hypoglycemic encephalopathy was poor, with only a small fraction of patients who slowly improved after intensive care unit discharge. Of note, patients who did not improve during the first 6 months did not recover consciousness. This study suggests that a multimodal approach capitalizing on advanced brain imaging and bedside electrophysiology techniques could improve diagnostic and prognostic performance in severe hypoglycemic encephalopathy.
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Affiliation(s)
- Aude Sangare
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France.
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France.
- Institut de Neurosciences Translationnelles, Paris, France.
- Brain Institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Clémence Marois
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
| | | | - Nadya Pyatigorskaya
- Département de Neuroradiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
| | - Mélanie Valente
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Julie Zyss
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Alaina Borden
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Virginie Lambrecq
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Loic Le Guennec
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jacobo Sitt
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
| | - Nicolas Weiss
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
- Brain Liver Pitié-Salpêtrière Study Group, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie & Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Benjamin Rohaut
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Sophie Demeret
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Louis Puybasset
- Laboratoire d'Imagerie Biomédicale, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Assistance Publique-Hôpitaux de Paris, Départements Médico-Universitaires Diagnostic, Radiologie, Explorations fonctionnelles, Anatomo-pathologie, Médecine nucléaire, Paris, France
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Demoule
- Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Santé et de la Recherche Médicale, Sorbonne Université, Paris, France
- Service Médecine Intensive-Réanimation, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Lionel Naccache
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
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Bouyaknouden D, Peddada TN, Ravishankar N, Fatima S, Fong-Isariyawongse J, Gilmore EJ, Lee JW, Struck AF, Gaspard N. Neurological Prognostication After Hypoglycemic Coma: Role of Clinical and EEG Findings. Neurocrit Care 2022; 37:273-280. [PMID: 35437670 DOI: 10.1007/s12028-022-01495-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypoglycemic coma (HC) is an uncommon but severe clinical condition associated with poor neurological outcome. There is a dearth of robust neurological prognostic factors after HC. On the other hand, there is an increasing body of literature on reliable prognostic markers in the postanoxic coma, a similar-albeit not identical-situation. The objective of this study was thus to investigate the use and predictive value of these markers in HC. METHODS We conducted a retrospective, multicenter, cohort study within five centers of the Critical Care EEG Monitoring Research Consortium. We queried our electroencephalography (EEG) databases to identify all patients undergoing continuous EEG monitoring after admission to an intensive care unit with HC (defined as Glasgow Coma Scale < 8 on admission and a first blood glucose level < 50 mg/dL or not documented but in an obvious clinical context) between 01/01/2010 and 12/31/2020. We studied the association of findings at neurological examination (Glasgow Coma Scale motor subscale, pupillary light and corneal reflexes) and at continuous EEG monitoring(highly malignant patterns, reactivity, periodic discharges, seizures) with best neurological outcome within 3 months after hospital discharge, defined by the Cerebral Performance Category as favorable (1-3: recovery of consciousness) versus unfavorable (4-5: lack of recovery of consciousness). RESULTS We identified 60 patients (30 [50%] women; age 62 [51-72] years). Thirty-one and 29 patients had a favorable and unfavorable outcome, respectively. The presence of pupillary reflexes (24 [100%] vs. 17 [81%]; p value 0.04) and a motor subscore > 2 (22 [92%] vs. 12 [63%]; p value 0.03) at 48-72 h were associated with a favorable outcome. A highly malignant EEG pattern was observed in 7 of 29 (24%) patients with unfavorable outcome versus 0 of 31 (0%) with favorable outcome, whereas the presence of EEG reactivity was observed in 28 of 31 (90%) patients with favorable outcome versus 13 of 29 (45%) with unfavorable outcome (p < 0.001 for comparison of all background categories). CONCLUSIONS This preliminary study suggests that highly malignant EEG patterns might be reliable prognostic markers of unfavorable outcome after HC. Other EEG findings, including lack of EEG reactivity and seizures and clinical findings appear less accurate. These findings should be replicated in a larger multicenter prospective study.
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Affiliation(s)
- Douaae Bouyaknouden
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Teja N Peddada
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, WI, USA
| | | | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI, USA.,William S. Middleton Veterans Hospital, Madison, WI, USA
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Neurology, Yale University, New Haven, CT, USA.
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Lee YE, Lee EJ, Lee SE, Park J. Predictors of consciousness improvement in patients with hypoglycemic encephalopathy. Front Endocrinol (Lausanne) 2022; 13:956367. [PMID: 36051391 PMCID: PMC9424633 DOI: 10.3389/fendo.2022.956367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS Hypoglycemic encephalopathy (HE) can cause long-lasting mental changes, disability, and even death. We aimed to investigate prognostic factors for HE and to determine when the treatment of HE becomes futile. METHODS We retrospectively evaluated the data of patients admitted for prolonged HE at Dongguk University Ilsan Hospital between December 2005 and July 2021. We assessed the Glasgow Outcome Scale (GOS) to assess functional outcome. RESULTS Forty-four patients were enrolled in the study. Thirty-two of these showed the improvement on GOS after treatment. Patients with improved consciousness had a shorter duration of hypoglycemia (1.6±1.4 vs. 7.8±15.0 hours, p = 0.04) and a lower incidence of brain lesions than those without improvements in consciousness (76.0% vs. 25.0%, p < 0.01). Patients whose lesions were detected in initial MRIs were 1.3 times less likely to recover consciousness after HE (odds ratios, 1.28; 95% CI, 1.09-1.52; p < 0.01). None of the patients recovered consciousness after 320 h. Maximum time spent to recover was 194 in patients without brain lesions and 319 in those with lesions. CONCLUSIONS Hypoglycemic brain injury detected in initial MRIs predicted poorer HE prognosis. Nevertheless, treatment should be provided for at least for 14 days after admission.
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Affiliation(s)
- Yu Eun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Eun Ja Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Seung Eun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
- *Correspondence: Jinkyeong Park, ; Seung Eun Lee,
| | - Jinkyeong Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, South Korea
- *Correspondence: Jinkyeong Park, ; Seung Eun Lee,
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Clinical applications of diffusion-weighted sequence in brain imaging: beyond stroke. Neuroradiology 2021; 64:15-30. [PMID: 34596716 PMCID: PMC8484843 DOI: 10.1007/s00234-021-02819-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/10/2021] [Indexed: 11/20/2022]
Abstract
Diffusion-weighted imaging (DWI) is a well-established MRI sequence for diagnosing early stroke and provides therapeutic implications. However, DWI yields pertinent information in various other brain pathologies and helps establish a specific diagnosis and management of other central nervous system disorders. Some of these conditions can present with acute changes in neurological status and mimic stroke. This review will focus briefly on diffusion imaging techniques, followed by a more comprehensive description of the utility of DWI in common neurological entities beyond stroke.
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8
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Jeon SJ, Choi SS, Kim HY, Yu IK. Acute Acquired Metabolic Encephalopathy Based on Diffusion MRI. Korean J Radiol 2021; 22:2034-2051. [PMID: 34564957 PMCID: PMC8628163 DOI: 10.3348/kjr.2019.0303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/02/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022] Open
Abstract
Metabolic encephalopathy is a critical condition that can be challenging to diagnose. Imaging provides early clues to confirm clinical suspicions and plays an important role in the diagnosis, assessment of the response to therapy, and prognosis prediction. Diffusion-weighted imaging is a sensitive technique used to evaluate metabolic encephalopathy at an early stage. Metabolic encephalopathies often involve the deep regions of the gray matter because they have high energy requirements and are susceptible to metabolic disturbances. Understanding the imaging patterns of various metabolic encephalopathies can help narrow the differential diagnosis and improve the prognosis of patients by initiating proper treatment regimen early.
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Affiliation(s)
- Se Jeong Jeon
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - See Sung Choi
- Department of Radiology, Wonkwang University Hospital, Iksan, Korea
| | - Ha Yon Kim
- Department of Radiology, Eulji University Hospital, Deajeon, Korea
| | - In Kyu Yu
- Department of Radiology, Eulji University Hospital, Deajeon, Korea.
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9
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Lux D, Edwards M, Zhang L. Suspecting unwitnessed hypoglycaemia. Pract Neurol 2021; 21:practneurol-2020-002887. [PMID: 33850032 DOI: 10.1136/practneurol-2020-002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/03/2022]
Abstract
Hypoglycaemic coma can present with acute neurological dysfunction mimicking stroke. It may be masked by normoglycaemia due to physiological compensatory mechanisms (Somogyi phenomenon). Specific MR brain scan changes should alert the clinician to consider this alternative to stroke in the acute setting in patients with a history of recurrent hypoglycaemia, even when the blood glucose is not low at presentation. Rapid identification and treatment of hypoglycaemia may confer a good prognosis with radiological resolution.
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Affiliation(s)
- Danielle Lux
- Department of Neurology and Stroke Medicine, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, Greater London, UK
| | - Mark Edwards
- Department of Neurology, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, Greater London, UK
| | - Liqun Zhang
- Department of Neurology and Stroke Medicine, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, Greater London, UK
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Affiliation(s)
- Tadayuki Takata
- Department of General Internal Medicine, Kagawa University Faculty of Medicine, Japan
- Department of Neurology, Kagawa University Faculty of Medicine, Japan
| | - Hiroki Yamana
- Department of Gastroenterology, Kagawa University Faculty of Medicine, Japan
| | - Hideki Kamada
- Department of Gastroenterology, Kagawa University Faculty of Medicine, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology, Kagawa University Faculty of Medicine, Japan
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11
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Tomita N, Nakamura T, Sunden Y, Morita T. Histopathological and immunohistochemical analysis of the cerebral white matter after transient hypoglycemia in rat. J Vet Med Sci 2019; 82:68-76. [PMID: 31787662 PMCID: PMC6983658 DOI: 10.1292/jvms.19-0502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Patients with hypoglycemic coma show abnormal signals in the white matter on magnetic resonance imaging. However, the precise pathological changes in the white matter caused by hypoglycemic
coma remain unclear in humans and experimental animals. This study aimed to reveal the distribution and time course of histopathological and immunohistochemical changes occurring in the
white matter during the early stages of hypoglycemic coma in rats. Insulin-induced hypoglycemic coma of 15–30-min duration was induced in rats, followed by recovery using a glucose solution.
Rat brains were collected after 6 and 24 hr and after 3, 5, 7, and 14 days. The brains were submitted for histological and immunohistochemical analysis for neurofilament 200 kDa (NF), myelin
basic protein, olig-2, Iba-1, and glial fibrillary acidic protein (GFAP). Vacuolation was observed in the fiber bundles of the globus pallidus on days 1–14. Most of the vacuoles were located
in GFAP-positive astrocytic processes or the extracellular space and appeared to be edematous. Additionally, myelin pallor and a decrease in NF-positive signals were observed on day 14.
Microgliosis and astrogliosis were also detected. Observations similar to the globus pallidus, except for edema, were noted in the internal capsule. In the corpus callosum, a mild decrease
in NF-positive signals, microgliosis, and astrogliosis were observed. These results suggest that after transient hypoglycemic coma, edema and/or degeneration occurred in the white matter,
especially in the globus pallidus, internal capsule, and corpus callosum in the early stages.
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Affiliation(s)
- Nagi Tomita
- Laboratory of Veterinary Pathology, Tottori University, Tottori, Tottori 680-8553, Japan.,The United Graduate School of Veterinary Science, Yamaguchi University, Yamaguchi, Yamaguchi 753-8511, Japan
| | - Tomoki Nakamura
- Laboratory of Veterinary Pathology, Tottori University, Tottori, Tottori 680-8553, Japan
| | - Yuji Sunden
- Laboratory of Veterinary Pathology, Tottori University, Tottori, Tottori 680-8553, Japan
| | - Takehito Morita
- Laboratory of Veterinary Pathology, Tottori University, Tottori, Tottori 680-8553, Japan
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12
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Gugger JJ, Geocadin RG, Kaplan PW. A multimodal approach using somatosensory evoked potentials for prognostication in hypoglycemic encephalopathy. Clin Neurophysiol Pract 2019; 4:194-197. [PMID: 31886445 PMCID: PMC6921239 DOI: 10.1016/j.cnp.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
Hypoglycemic encephalopathy may be associated with poor neurological prognosis. Little data exists to guide prognostication in hypoglycemic encephalopathy. We describe a multimodal approach to prognostication in hypoglycemia. MRI, EEG, and SSEPs estimate severity of brain injury in hypoglycemic coma.
Objectives We present a case of a patient with hypoglycemic encephalopathy with loss of median nerve N20 somatosensory evoked potentials (SSEPs) and describe our multimodal approach to prognostication in hypoglycemic encephalopathy. Case The patient was a 67-year-old woman with type 2 diabetes and stage 5 chronic kidney disease hospitalized for hypoglycemic encephalopathy. SSEPs showed bilateral absence of the median nerve N20 response. She ultimately suffered a poor outcome. Discussion There are no high-quality evidence-based clinical, neurophysiologic, or imaging studies available to aid in neurologic outcome prediction in hypoglycemic encephalopathy. In our practice we use a multimodal approach to neurologic prognostication, similar to that used in coma after cardiac arrest that includes SSEPs, EEG, and brain MRI, which enables an estimate of the severity of brain injury. As the literature is largely based on small studies or case reports, and is extrapolated from the cardiac arrest literature, we caution against early prognostication and disposition including the withdrawal of care, to avoid a self-fulfilling prophecy.
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Affiliation(s)
- James J Gugger
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tong F, Zou Y, Liang Y, Lei H, Lopsong T, Liu Y, Le Grange JM, He G, Zhou Y. The Water Diffusion of Brain Following Hypoglycemia in Rats – A Study with Diffusion Weighted Imaging and Neuropathologic Analysis. Neuroscience 2019; 409:58-68. [DOI: 10.1016/j.neuroscience.2019.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 01/26/2023]
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Saikawa R, Yamada H, Suzuki D, Amamoto M, Matsumoto Y, Funazaki S, Yoshida M, Toyoshima H, Hara K. Risk Factors of Hypoglycemic Encephalopathy and Prolonged Hypoglycemia in Patients With Severe Hypoglycemia. J Clin Med Res 2019; 11:213-218. [PMID: 30834045 PMCID: PMC6396785 DOI: 10.14740/jocmr3728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/31/2018] [Indexed: 11/11/2022] Open
Abstract
Background The aim of the study was to investigate risk factors of hypoglycemic encephalopathy (HE) in patients with severe hypoglycemia. Methods We retrospectively enrolled patients with severe hypoglycemia who were transported to the emergency department in an ambulance. We defined severe hypoglycemia as plasma glucose level < 60 mg/dL (or capillary levels < 50 mg/dL). HE was defined as severe hypoglycemia with altered level of consciousness (Glasgow coma scale < 12) and prolonged HE as coma or stupor lasting > 24 h after glucose administration. We compared several parameters between patients with and without HE and between prolonged and recovered patients. Results Included were 173 patients with severe hypoglycemia; of them, 94 were diagnosed with HE, with 12 of them prolonged HE. Glucose level in HE patients was lower than that in those without HE (P < 0.001). Moreover, we noted a significant difference in glucose levels between the prolonged and recovered groups. Furthermore, body temperature was higher in prolonged versus recovered patients (P = 0.0017). Conclusion Blood glucose level may be correlated with severity of altered level of consciousness. In addition, body temperature may be related to coma or prolonged stupor.
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Affiliation(s)
- Rika Saikawa
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Hodaka Yamada
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Daisuke Suzuki
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Misato Amamoto
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Yuko Matsumoto
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Shunsuke Funazaki
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Masashi Yoshida
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Hideo Toyoshima
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
| | - Kazuo Hara
- Department of Medicine, Division of Endocrinology and Metabolism, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Japan
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Brown AM, Evans RD, Smith PA, Rich LR, Ransom BR. Hypothermic neuroprotection during reperfusion following exposure to aglycemia in central white matter is mediated by acidification. Physiol Rep 2019; 7:e14007. [PMID: 30834716 PMCID: PMC6399195 DOI: 10.14814/phy2.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 11/24/2022] Open
Abstract
Hypoglycemia is a common iatrogenic consequence of type 1 diabetes therapy that can lead to central nervous system injury and even death if untreated. In the absence of clinically effective neuroprotective drugs we sought to quantify the putative neuroprotective effects of imposing hypothermia during the reperfusion phase following aglycemic exposure to central white matter. Mouse optic nerves (MONs), central white matter tracts, were superfused with oxygenated artificial cerebrospinal fluid (aCSF) containing 10 mmol/L glucose at 37°C. The supramaximal compound action potential (CAP) was evoked and axon conduction was assessed as the CAP area. Extracellular lactate was measured using an enzyme biosensor. Exposure to aglycemia, simulated by omitting glucose from the aCSF, resulted in axon injury, quantified by electrophysiological recordings, electron microscopic analysis confirming axon damage, the extent of which was determined by the duration of aglycemia exposure. Hypothermia attenuated injury. Exposing MONs to hypothermia during reperfusion resulted in improved CAP recovery compared with control recovery measured at 37°C, an effect attenuated in alkaline aCSF. Hypothermia decreases pH implying that the hypothermic neuroprotection derives from interstitial acidification. These results have important clinical implications demonstrating that hypothermic intervention during reperfusion can improve recovery in central white matter following aglycemia.
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Affiliation(s)
- Angus M. Brown
- School of Life SciencesQueens Medical CentreUniversity of NottinghamNottinghamUnited Kingdom
- Department of NeurologySchool of MedicineUniversity of WashingtonSeattleWashington
| | - Richard D. Evans
- School of Life SciencesQueens Medical CentreUniversity of NottinghamNottinghamUnited Kingdom
| | - Paul A. Smith
- School of Life SciencesQueens Medical CentreUniversity of NottinghamNottinghamUnited Kingdom
| | - Laura R. Rich
- School of Life SciencesQueens Medical CentreUniversity of NottinghamNottinghamUnited Kingdom
| | - Bruce R. Ransom
- Department of NeurologySchool of MedicineUniversity of WashingtonSeattleWashington
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Miyakawa Y, Fuchigami T, Aoki M, Mine Y, Suzuki J, Urakami T, Takahashi S. Agraphia with reversible splenial corpus callosum lesion caused by hypoglycemia. Brain Dev 2018; 40:592-595. [PMID: 29606344 DOI: 10.1016/j.braindev.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/24/2018] [Accepted: 03/14/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Neurological manifestations caused by hypoglycemia range from reversible focal deficits and transient encephalopathy to irreversible coma or death. Recently, high signal intensity lesions in the splenium of the corpus callosum on diffusion-weighted magnetic resonance imaging were reported in adults experiencing hypoglycemia. However, patients presenting with agraphia are rare. SUBJECT AND METHODS We examined a 17-year-old left-handed female patient with type 1 diabetes who exhibited transient left agraphia with a reversible splenium lesion of the corpus callosum on diffusion-weighted imaging caused by hypoglycemia, which was improved with blood glucose management alone. CONCLUSION This rare case indicates that agraphia, a sign of callosal disconnection syndrome, can result from a reversible splenial lesion of the corpus callosum caused by hypoglycemia.
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Affiliation(s)
- Yukari Miyakawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuo Fuchigami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan.
| | - Masako Aoki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Yusuke Mine
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Junichi Suzuki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Shori Takahashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Imaging the Unconscious “Found Down” Patient in the Emergency Department. Neuroimaging Clin N Am 2018; 28:435-451. [DOI: 10.1016/j.nic.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sugita Y, Koyanagi M, Oda M, Kobayashi T, Narumi O, Saiki M. Severe Hypoglycemia-induced Right Hemiparesis with Reversible Diffusion Restriction in the Left Internal Capsule Due to Combination Therapy Using Disopyramide and Clarithromycin. NMC Case Rep J 2018; 5:31-33. [PMID: 29354336 PMCID: PMC5767484 DOI: 10.2176/nmccrj.cr.2017-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/22/2017] [Indexed: 11/23/2022] Open
Abstract
Severe hypoglycemia is known to cause acute focal neurological symptoms. In cases with a medical history of diabetes mellitus (DM), the diagnosis and treatment of hypoglycemia-induced neurological symptoms are simple. However, severe hypoglycemia can occur in patients who are not taking hypoglycemic agents such as insulin or long-acting sulfonylurea drugs. We describe a 95-year-old man with sudden onset of right hemiparesis who showed high signal intensity on diffusion-weighted imaging involving the left internal capsule with corresponding reduced apparent diffusion coefficient hypointensity. Laboratory findings revealed severe hypoglycemia (27 mg/dl). However, he was not taking insulin or long-acting sulfonylurea drugs but disopyramide and clarithromycin had been administered. In addition, he had kidney dysfunction with an estimated glomerular filtration rate (GFR) of 42.9 ml/min/1.73 m2. After the blood glucose level was normalized, the left hemiparesis completely recovered and abnormal findings of magnetic resonance imaging (MRI) study also became normal. A combination of disopyramide and clarithromycin may cause severe hypoglycemia-induced neurological symptoms particularly in patients with kidney dysfunction. Even in a patient with sudden-onset hemiparesis and no history of DM, the possibility of hypoglycemia-induced neurological deficit should be considered.
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Affiliation(s)
- Yoshito Sugita
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Masaomi Koyanagi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Masashi Oda
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Tamaki Kobayashi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Osamu Narumi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Masaaki Saiki
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
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Yedavalli V, Nyberg EM, Chow DS, Thaker AA. Beyond the embolus: "do not miss" diffusion abnormalities of ischaemic and non-ischaemic neurological disease. Insights Imaging 2017; 8:573-580. [PMID: 28986862 PMCID: PMC5707221 DOI: 10.1007/s13244-017-0574-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/21/2017] [Accepted: 09/04/2017] [Indexed: 11/23/2022] Open
Abstract
Abstract Given the rapid evolution and technological advances in the diagnosis and treatment of acute ischaemic stroke (AIS), including the proliferation of comprehensive stroke centres and increasing emphasis on interventional stroke therapies, the need for prompt recognition of stroke due to acute large vessel occlusion has received significant attention in the recent literature. Diffusion-weighted imaging (DWI) is the gold standard for the diagnosis of acute ischaemic stroke, as images appear positive within minutes of ischaemic injury, and a high signal-to-noise ratio enables even punctate infarcts to be readily detected. DWI lesions resulting from a single arterial embolic occlusion or steno-occlusive lesion classically lateralise and conform to a specific arterial territory. When there is a central embolic source (e.g. left atrial thrombus), embolic infarcts are often found in multiple vascular territories. However, ischaemic disease arising from aetiologies other than arterial occlusion will often not conform to an arterial territory. Furthermore, there are several important entities unrelated to ischaemic disease that can present with abnormal DWI and which should not be confused with infarct. This pictorial review explores the scope and typical DWI findings of select neurologic conditions beyond acute arterial occlusion, which should not be missed or misinterpreted. Teaching points • DWI abnormalities due to acute arterial occlusion must be promptly identified. • DWI abnormalities not due to arterial occlusion will often not conform to an arterial territory. • Several important non-ischaemic entities can present on DWI and should not be confused with infarct.
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Affiliation(s)
- Vivek Yedavalli
- Department of Diagnostic Radiology, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
| | - Eric M Nyberg
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Daniel S Chow
- Department of Radiological Sciences, UC Irvine Health School of Medicine, Orange, CA, 92868, USA
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
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20
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Functional outcome of patients with prolonged hypoglycemic encephalopathy. Ann Intensive Care 2017; 7:54. [PMID: 28534234 PMCID: PMC5440422 DOI: 10.1186/s13613-017-0277-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 05/08/2017] [Indexed: 11/22/2022] Open
Abstract
Background Little is known about the causes, clinical course and long-term outcome of comatose patients with prolonged hypoglycemic encephalopathy. Methods In a multicenter retrospective study conducted in patients hospitalized from July 1, 2004, to July 1, 2014, we investigated functional long-term prognosis and identified prognosis factors of patients admitted in an intensive care unit (ICU) with prolonged neurological manifestations related to hypoglycemia. Eligible patients were adults admitted to the ICU with a Glasgow Coma Score <8 due to hypoglycemia and persistent consciousness disorders after normalizing blood glucose levels. Patients with possible other causes of consciousness disorders, previous cognitive disorders, hypothermia <35 °C or circulatory arrest within 24 h after ICU admission, were excluded. Follow-up phone call was used to determine patients’ functional outcome using modified Rankin Scale (mRS) at a minimum of 1-year follow-up with mRS 0–3 defining good and mRS 4–6 poor outcomes. Results Forty-nine patients were included. Causes of hypoglycemia were various, mainly including insulin or oral antidiabetic drugs abuse (65%) and neuroendocrine carcinoma (16%). Twenty (41%) patients died in the ICU, two (4%) patients further died and nine (18%) patients had a poor outcome at long-term follow-up. Five patients discharged from the ICU with mRS > 3 improved enough to be in the good outcome group 1 year later. Twenty-two (45%) patients underwent therapeutic limitation, mainly related to no expected hope for improvement. On multivariate analysis, only low mRS prior to ICU admission (OR 2.6; 95% CI 1.1–6.3; P = 0.03) and normal brain imaging (OR 7.1; 95% CI 1.1–44; P = 0.03) were significantly predictive of a good outcome. All patients (n = 15) who remained hypoglycemic >480 min had a poor outcome. Conclusion Poor outcome was observed in about 60% of this population of hypoglycemic encephalopathy. However, some patients can recover satisfactorily over time.
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21
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Jeon JY, Kim SR, Kim HJ, Kim DJ, Lee KW, Lee JD, Han SJ. Risk factors of severe hypoglycemia requiring medical assistance and neurological sequelae in patients with diabetes: A case-control study. Medicine (Baltimore) 2016; 95:e5365. [PMID: 27893672 PMCID: PMC5134865 DOI: 10.1097/md.0000000000005365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P = 0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P = 0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P = 0.04) and to have a longer time from last seen normal till glucose administration (5.2 hours vs 1.6 hours, P = 0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.
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Affiliation(s)
| | | | | | | | | | - Jung-Dong Lee
- Office of Biostatistics, Ajou University School of Medicine, Suwon, Republic of Korea
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22
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Abstract
Hypoglycemic brain injury is usually reversible, and partial recovery or mortality depends on the affected area. Diffusion-weighted imaging (DWI) may be useful in predicting the prognosis according to the site of involvement. Isolated lesions of the splenium of corpus callosum (SCC) in hypoglycemic brain injury are very rare, and DWI findings of a reversible lesion of the SCC due to deep hypoglycemia associated with sulfonylurea intoxication has been reported only once in the literature. We report the case of a 15-year-old girl admitted to the emergency department who had attempted suicide using sulfonylurea and subsequently went into a coma. The patient had no known previous disease. Except for a blood glucose level of 10 mg/dl, all other blood laboratory tests were normal. DWI performed two hours after admission showed diffusion restriction in the SCC. After receiving treatment for 24 hours, the patient became conscious, and her blood glucose level returned to normal. Two days later, complete resolution of the SCC lesion was revealed by control DWI. We discuss both the DWI findings of the reversible SCC lesion due to hypoglycemic brain injury resulting from sulfonylurea intoxication and the role of DWI in predicting the clinical outcome.
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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; 353:98-101. [PMID: 25912175 DOI: 10.1016/j.jns.2015.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/28/2015] [Accepted: 04/10/2015] [Indexed: 10/23/2022]
Abstract
Our aim was to investigate the clinical and radiological features of patients with hypoglycemia with focal neurological signs (HFNS). Among 80 consecutive hypoglycemic patients (blood glucose levels less than 50mg/dL), who had been admitted between October 2008 and May 2012, we selected 11 patients (6 men and 5 women; mean age, 73.2 ± 12 years) with focal neurological signs. The mean initial blood glucose level was 27.9 mg/dL (range, 13-39 mg/dL). The most frequent symptom was unilateral motor weakness (n = 9), which was usually accompanied with mild or moderate alteration of consciousness. All patients had improved initial neurological signs within 1h of glucose injection. The initial DWI demonstrated a hyperintense lesion in the contralateral internal capsule with decreased values on the ADC (apparent diffusion coefficient) map in 2 of the patients (18%). The DWI performed one day later shows only faint lesion. The initial DWI in patients with HFNS may display a hyperintense lesion, which was difficult to distinguish from acute cerebral infarction. Hypoglycemia should be considered in cases with DWI showing a disproportionally small lesion in contrast to neurological signs.
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Affiliation(s)
- Tomohiko Ohshita
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Eiichi Nomura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | | | - Hiroshi Kajikawa
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.
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Slater L, Stuckey SL, Thyagarajan D, Chandra R. Reversible Corona Radiata Diffusion Restriction in Hypoglycemic Coma. Neurohospitalist 2015; 5:45-6. [DOI: 10.1177/1941874414532473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- L. Slater
- Department of Diagnostic Imaging, Neuroradiology service, Monash Health, Melbourne, Australia
| | - S. L. Stuckey
- Department of Diagnostic Imaging, Neuroradiology service, Monash Health, Melbourne, Australia
| | - D. Thyagarajan
- Department of Neurology, Monash Health, Melbourne, Australia
| | - R.V. Chandra
- Department of Diagnostic Imaging, Neuroradiology service, Monash Health, Melbourne, Australia
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MR screening of candidates for thrombolysis: How to identify stroke mimics? J Neuroradiol 2014; 41:283-95. [PMID: 25451670 DOI: 10.1016/j.neurad.2014.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022]
Abstract
Stroke mimics account for up to a third of suspected strokes. The main causes are epileptic deficit, migraine aura, hypoglycemia, and functional disorders. Accurate recognition of stroke mimics is important for adequate identification of candidates for thrombolysis. This decreases the number of unnecessary treatments and invasive vascular investigations. Correctly identifying the cause of symptoms also avoids delaying proper care. Therefore, this pictorial review focuses on what the radiologist should know about the most common MRI patterns of stroke mimics in the first hours after onset of symptoms. The issues linked to the accurate diagnosis of stroke mimics in the management of candidates for thrombolysis will be discussed.
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Deleo F, Matricardi S, Didato G, Montano N, Gnatkovsky V, Romito LM, Battaglia G, Spreafico R, Villani F. An unusual behavioural and motor paroxysmal disorder caused by insulinoma-related hypoglycemia: a possible cause of epilepsy misdiagnosis. Seizure 2014; 23:909-11. [PMID: 25088567 DOI: 10.1016/j.seizure.2014.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/29/2014] [Accepted: 06/30/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Giuseppe Didato
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences, Internal Medicine II, L. Sacco Hospital, University of Milan, Ospedale L. Sacco, Milan, Italy
| | - Vadym Gnatkovsky
- Experimental Neurophysiology and Epileptology Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Luigi Michele Romito
- Movement Disorders Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Giorgio Battaglia
- Molecular Neuroanatomy and Pathogenesis Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Roberto Spreafico
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico 'C. Besta', Milan, Italy.
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Yang X, Hamner MA, Brown AM, Evans RD, Ye ZC, Chen S, Ransom BR. Novel hypoglycemic injury mechanism: N-methyl-D-aspartate receptor-mediated white matter damage. Ann Neurol 2014; 75:492-507. [DOI: 10.1002/ana.24050] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/29/2013] [Accepted: 09/27/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Xin Yang
- Department of Neurology; Ruijin Hospital; affiliated with Shanghai Jiaotong University School of Medicine; Shanghai China
| | | | - Angus M. Brown
- School of Biomedical Sciences; University of Nottingham; Nottingham United Kingdom
| | - Richard D. Evans
- School of Biomedical Sciences; University of Nottingham; Nottingham United Kingdom
| | - Zu-Cheng Ye
- Department of Neurology; University of Washington; Seattle WA
| | - Shengdi Chen
- Department of Neurology; Ruijin Hospital; affiliated with Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Bruce R. Ransom
- Department of Neurology; University of Washington; Seattle WA
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Yamashita C, Shigeto H, Maeda N, Kawaguchi M, Uryu M, Motomura S, Kira JI. Transient interhemispheric disconnection in a case of insulinoma-induced hypoglycemic encephalopathy. J Neurol Sci 2013; 335:233-7. [PMID: 24139556 DOI: 10.1016/j.jns.2013.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 09/10/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022]
Abstract
We report a case of a 22-year-old male who was transferred to our hospital in a comatose state following successive seizures. Low blood glucose had been detected upon his arrival at the previous hospital. He became responsive 12 days after the onset of coma. Upon regaining consciousness he exhibited severe dysarthria and several interhemispheric disconnection signs such as intermanual conflict, left-hand dysgraphia, left hemispatial neglect confined to the right hand, impaired interhemispheric transfer, and unilateral constructional apraxia of the right hand. Brain MRI disclosed T2-weighted and diffusion-weighted hyperintense lesions with reduced apparent diffusion coefficients in the bilateral centrum semiovale, splenium of the corpus callosum, right posterior limb of the internal capsule, and bilateral middle cerebellar peduncles. As the MRI findings vanished, his interhemispheric disconnection signs gradually resolved. Abdominal imaging studies revealed a pancreatic tumor, which was later endocrinologically diagnosed as an insulinoma. This is an extremely rare report of interhemispheric disconnection signs due to hypoglycemic encephalopathy. The lesions in the bilateral centrum semiovale likely contributed to the interhemispheric disconnection signs.
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Affiliation(s)
- Chikara Yamashita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Japan
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Swanson RA. Glucose, acid, and aspartate: Friends and foes of the axon. Ann Neurol 2013; 75:490-1. [PMID: 24272667 DOI: 10.1002/ana.24071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 11/18/2013] [Accepted: 11/19/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Raymond A Swanson
- Department of Neurology, University of California, San Francisco and Neurology Service San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Yokoi S, Yasui K, Hasegawa Y, Kasai T, Inagaki A, Sobue G. [A case of hypoglycemic coma with good outcome despite sustained unconsciousness and widespread leukoencephalopathy]. Rinsho Shinkeigaku 2013; 53:724-7. [PMID: 24097322 DOI: 10.5692/clinicalneurol.53.724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We described a 28-year-old woman with insulinoma-induced hypoglycemic coma. Her initial diffusion-weighted MRI revealed diffuse hyperintense lesions involving bilateral hemispheric white matter. She did not respond to the initial treatment with glucose. However, after surgical removal of insulinoma, she began to recover gradually, and 1 year later, returned to her previous work. In general, the outcome of hypoglycemic coma with widespread leukoencephalopathy on MRI is thought to be poor. However, we should be aware that some of such cases could recover in the long term.
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Affiliation(s)
- Satoshi Yokoi
- Department of Neurology, Nagoya Daini Red Cross Hospital
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Ikeda T, Takahashi T, Sato A, Tanaka H, Igarashi S, Fujita N, Kuwabara T, Kanazawa M, Nishizawa M, Shimohata T. Predictors of outcome in hypoglycemic encephalopathy. Diabetes Res Clin Pract 2013; 101:159-63. [PMID: 23820485 DOI: 10.1016/j.diabres.2013.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/18/2013] [Accepted: 05/29/2013] [Indexed: 12/27/2022]
Abstract
AIMS The aim of this study was to investigate factors predicting poor prognosis in patients with hypoglycemic encephalopathy. METHODS We retrospectively analyzed data on 165 consecutive patients with hypoglycemic encephalopathy. We evaluated their outcome 1 week after hypoglycemia onset using the Glasgow outcome scale (GOS) and compared the clinical features of patients with good outcomes (GOS = 5) and poor outcomes (GOS ≤ 4). RESULTS The poor-outcome group included 38 patients (23%). The initial blood glucose level in the poor-outcome group was lower than that in the good-outcome group (p = 0.002). The duration of hypoglycemia in the poor-outcome group was longer than that in the good-outcome group (p < 0.001). Body temperature during hypoglycemia in the poor-outcome group was higher than that in the good-outcome group (p < 0.001). Furthermore, lactic acid level in the poor-outcome group was lower than in the good-outcome group (p = 0.032). There was no significant difference in the frequency of posttreatment hyperglycemia between the good-outcome and poor-outcome groups (p = 0.984). CONCLUSION Profound and prolonged hypoglycemia, normal or higher body temperature, and a low lactic acid level during hypoglycemia may be predictors of a poor outcome in patients with hypoglycemic encephalopathy.
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Affiliation(s)
- Tetsuhiko Ikeda
- Department of Neurology, Brain Research Institute, Niigata University, Japan
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Bathla G, Policeni B, Agarwal A. Neuroimaging in patients with abnormal blood glucose levels. AJNR Am J Neuroradiol 2013; 35:833-40. [PMID: 23639559 DOI: 10.3174/ajnr.a3486] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY Smooth neuronal functioning requires an uninterrupted supply of energy that is provided by glucose under normal physiologic conditions. Significant variations in plasma glucose levels, be it hypoglycemia or hyperglycemia, can present with myriad clinical manifestations and may mimic stroke. At times, the diagnosis is either not apparent or not clinically suspected. Imaging can suggest the diagnosis in unsuspected cases and can help in the assessment of the extent of neuronal damage in known cases, making it vital for the neuroradiologist to be aware of both common and atypical neuroimaging findings in hypoglycemia and hyperglycemia.
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Affiliation(s)
- G Bathla
- From the Department of Radiology (G.B., B.P.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - B Policeni
- From the Department of Radiology (G.B., B.P.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - A Agarwal
- Penn State College of Medicine (A.A.), Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Menezes MP, Nowland T, Onikul E. Diffusion-weighted imaging changes caused by acute hypoglycemia and prolonged febrile convulsion in childhood. AJNR Am J Neuroradiol 2013; 34:E43-4. [PMID: 23471020 DOI: 10.3174/ajnr.a3527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
The vast majority of restricted-diffusion abnormalities result from acute stroke, and as such, the diagnosis may be problematic when this MRI feature results from other causes. Distinct patterns of restricted diffusion seen with various disease conditions can play an important diagnostic role. The association of certain diseases with a given restricted-diffusion pattern allows for a focused assessment to determine a specific etiology.
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Affiliation(s)
- Pasquale F Finelli
- Department of Neurology, Hartford Hospital and University of Connecticut School of Medicine, Hartford
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