Hypoglycemia: Stroke-Like Symptoms And Their Causes

Hypoglycemia can cause stroke-like symptoms, and it is important to be aware of this to ensure a correct diagnosis and prompt treatment.

Signs of an acute stroke, such as hemiplegia, aphasia, and cortical blindness, have been reported with hypoglycemia. In individuals with low glycemic levels and stroke-like symptoms, diabetes mellitus may have been previously diagnosed, and recent changes in the doses of hypoglycemic agents and insulin may have been instituted.

In the setting of acute stroke, obtaining serum glucose levels is routine practice. If stroke-like symptoms are a result of hypoglycemia, a CT scan of the head may initially be normal. Later, in patients with severe hypoglycemia that is prolonged and complicated by anoxic brain injury and coma, CT scanning of the brain may show cortical atrophy (reflecting laminar necrosis). If the hypoglycemia is transitory and the clinical status of the patient returns to normal, follow-up CT-scan findings may again be normal.

In the literature, hypoglycemia has been reported as the cause of symptoms mimicking acute stroke in 3 out of 1460 patients admitted to a stroke unit over a 5-year period. Acute hypoglycemia may mimic acute ischemic stroke, but it can also present as transient hemineglect syndrome.

In summary, some clinical evidence suggests that exposure to hypoglycemia increases the risk of cerebrovascular events in diabetic patients. It is also possible that hypoglycemia may indirectly affect stroke risk, as increased incidences of hypoglycemia may also reflect underlying poor health that predisposes to adverse vascular outcomes.

Hypoglycemia can cause hemiplegia, aphasia, and cortical blindness

A 55-year-old female with diabetes, for example, experienced sudden onset unilateral cerebellar symptoms during a hypoglycemic episode. Her symptoms included an inability to maintain posture and impaired coordination in body movements. After receiving an infusion of 10% dextrose, her cerebellar signs completely resolved within 20 minutes.

In another case, a 7-year-old boy with glycogen storage disease type III experienced transient acute cortical blindness associated with hypoglycemia on two separate occasions.

Additionally, the most common diffusion-weighted MR imaging finding in patients with hypoglycemic hemiplegia is the hyperintense lesion involving the internal capsule, mimicking acute ischemic stroke. This emphasizes the importance of differentiating hypoglycemia from other conditions by immediate blood glucose measurement in patients presenting with acute hemiplegia.

Furthermore, current research indicates a potential link between recurrent hypoglycemia and adverse neurovascular events in diabetic patients. Repeated episodes of hypoglycemia can weaken the body's neuroglycopenic response to low blood glucose, leading to a higher risk of developing hypoglycemia-associated autonomic failure (HAAF).

Therefore, it is crucial to rule out hypoglycemia in patients presenting with stroke-like symptoms, as prompt correction of blood glucose levels may prevent further neuronal damage and improve symptoms.

Hypoglycemia can be caused by overuse of oral hypoglycemic agents or insulin

Hypoglycemia can be caused by the overuse of oral hypoglycemic agents or insulin. Oral hypoglycemic agents are used only in the treatment of type 2 diabetes, which involves resistance to secreted insulin. Type 1 diabetes involves a lack of insulin and requires insulin for treatment. There are now four classes of hypoglycemic drugs: alpha-glucosidase inhibitors, sulfonylureas, repaglinide, and metformin.

Sulfonylureas are the most widely used drugs for treating type 2 diabetes and work by stimulating insulin secretion. They increase the responsiveness of beta cells (insulin-secreting cells located in the pancreas) to glucose and non-glucose secretagogues, resulting in more insulin being released at all blood glucose concentrations. Sulfonylureas are usually well-tolerated, but hypoglycemia is their most common side effect. This is more common with long-acting sulfonylureas, and patients recently discharged from the hospital are at the highest risk. Other side effects include nausea, skin reactions, and abnormal liver function tests.

Repaglinide is a short-acting glucose-lowering drug recently approved for the treatment of type 2 diabetes. It acts similarly to sulfonylureas by increasing insulin secretion. The recommended starting dose is 0.5 mg before each meal for patients who have not previously taken oral hypoglycemic drugs, with a maximum dose of 4 mg before each meal. Hypoglycemia is its most common adverse effect.

Metformin has been used in Europe for over thirty years and has been available in the United States since 1995. It is effective only in the presence of insulin and does not directly stimulate insulin secretion. Instead, its major effect is to increase insulin action. Metformin is most often used in obese patients with type 2 diabetes because it promotes modest weight reduction or stabilization. It is less likely to cause hypoglycemia than sulfonylureas and has prominent lipid-lowering activity. However, it can cause gastrointestinal side effects and, rarely, lactic acidosis.

Alpha-glucosidase inhibitors include acarbose and miglitol and are available in the United States. They inhibit the upper gastrointestinal enzymes that convert dietary starch and other complex carbohydrates into simple sugars, slowing the absorption of glucose after meals. Their main side effects are flatulence and diarrhea, which are usually mild.

Hypoglycemia is a common issue for people with diabetes, especially those who take insulin to manage their condition. It can also sometimes affect people without diabetes, though this is uncommon. It requires immediate treatment by consuming carbohydrates and can be life-threatening if left untreated. Symptoms of hypoglycemia can vary from person to person and can include shaking, sweating, extreme hunger, dizziness, confusion, anxiety, and numbness in the lips, tongue, or cheeks. Severe hypoglycemia can lead to blurred or double vision, clumsiness, loss of consciousness, and even death.

Hypoglycemia can be a stroke mimic

In the setting of acute stroke, obtaining the following is routine practice: serum glucose levels, complete blood count (CBC), prothrombin time (PT), and activated partial thromboplastin time (aPTT). If stroke-like symptoms are a result of hypoglycemia, a CT scan of the head may initially be normal. Later, in patients with severe hypoglycemia that is prolonged and complicated by anoxic brain injury and coma, CT scanning of the brain may show cortical atrophy (reflecting laminar necrosis). If the hypoglycemia is transitory and the clinical status of the patient returns to normal, follow-up CT-scan findings may again be normal.

In a study, Berkovic et al. reported that hypoglycemia was the cause of symptoms mimicking acute stroke in 3 out of 1460 patients admitted to their stroke unit over a 5-year period. In another study, CT perfusion of the brain of a 60-year-old male with known diabetes mellitus who was brought to the hospital as a stroke alert showed a decreased perfusion in the right cortical area. The episode was attributed to severe hypoglycemia because of a recent medication change.

In a case study, a 69-year-old right-handed diabetic male with no prior history of transient ischemic attack (TIA) presented with two transient episodes of language disturbance and right hemiparesis on consecutive days. The patient did not exhibit any autonomic features. His non-contrast head CT was unremarkable except for the presence of leukoaraiosis, and an arch-to-vertex CT angiography (CTA) showed no extra or intracranial arterial occlusion while the CT perfusion revealed left parieto-occipital hypoperfusion located predominantly in the white matter. The resolution of symptoms for each event occurred following the return of the blood glucose to the normal range.

In summary, hypoglycemia can be a stroke mimic. Hypoglycemia should be included in the differential diagnosis for acute neurological impairment, including hemineglect. Abnormal brain imaging can be present. It should also be emphasized that focal neurological deficits from hypoglycemia may not have an immediate resolution after correcting the glucose level.

Hypoglycemia can cause seizures

In people with diabetes, severe hypoglycemia can cause coma, seizures, and brain damage and can even be fatal. The risk of hypoglycemia is higher in people with type 1 diabetes, and it is a common complication of insulin treatment. During hypoglycemia, the body releases catecholamines to increase hepatic glucose production and restore normal glucose concentrations. However, this can lead to unintended consequences such as increased platelet aggregation, fatal arrhythmias, and chronic cardiac inflammation.

Acute symptomatic hypoglycemia can cause stroke-like symptoms, including hemiparesis, and can mimic ischemic stroke on brain imaging. Brain imaging abnormalities in patients with hypoglycemia are uncommon but can be weakly associated with neurological deficits. About 20% of cases of hypoglycemia may mimic acute ischemic stroke on imaging, typically by causing unilateral cortical and subcortical tissue hypoattenuation and swelling or lacunar ischemic stroke.

The presence and severity of seizures are associated with mortality in hypoglycemia. Severe hypoglycemia can cause sudden death through two distinct pathways: seizures leading to respiratory arrest and cardiac arrhythmias leading to fatal bradycardia. Preventing both seizures and cardiac arrhythmias is necessary to prevent hypoglycemia-induced mortality.

Hypoglycemia can cause dizziness, shakiness, irregular heartbeat, and severe headache

Hypoglycemia, or low blood sugar, can cause dizziness, shakiness, irregular heartbeat, and severe headaches. It is a condition that occurs when blood sugar levels drop below 70 mg/dL and can be life-threatening if left untreated. Here are some detailed paragraphs on each of the mentioned symptoms:

Dizziness

Hypoglycemia can cause dizziness due to a drop in blood glucose levels, which the body relies on for energy. This is particularly common in people with diabetes, where blood sugar levels can fluctuate due to medication, diet, or exercise. Dizziness may be accompanied by other symptoms such as weakness, fatigue, and confusion. It is important for individuals experiencing dizziness to check their blood sugar levels and take appropriate action to raise their glucose levels.

Shakiness

Shakiness or trembling is a common symptom of hypoglycemia. When blood sugar levels drop, the body may release adrenaline, which can cause shakiness and a rapid heartbeat. This is a result of the body's fight-or-flight response, which is triggered when blood glucose levels fall too low. Other symptoms that may accompany shakiness include nervousness, sweating, and hunger. It is crucial to address shakiness caused by low blood sugar promptly to prevent more severe complications.

Irregular Heartbeat

Hypoglycemia can lead to an irregular heartbeat, also known as cardiac arrhythmia. This occurs because low blood sugar levels can affect the heart's electrical system, causing the heart to beat too fast or too slow. Hypoglycemia-induced arrhythmias are more common in people with type 2 diabetes and cardiovascular risk factors. The risk of arrhythmias increases during nocturnal hypoglycemia, where blood sugar levels can drop significantly while sleeping. It is important to manage diabetes effectively and monitor blood sugar levels regularly to reduce the risk of arrhythmias.

Severe Headache

Headaches are a common symptom of hypoglycemia and can be dull, throbbing pains in the temples. Hypoglycemic headaches may be accompanied by other symptoms such as blurry vision, increased heart rate, nervousness, fatigue, and irritability. In some cases, hypoglycemia can also trigger migraine headaches. It is important to treat hypoglycemic headaches promptly by raising blood sugar levels and seeking medical attention if necessary.

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