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November 03, 2020; 95 (18) Resident & Fellow Section

Teaching NeuroImages: Nonketotic hyperglycemic hyperosmolar state mimicking acute ischemic stroke

Marta I. Bala, Anibal Chertcoff, Miguel Saucedo, Fabio Gonzalez, Luis A. Miquelini, Pablo Bonardo, Ricardo Reisin
First published August 14, 2020, DOI: https://doi.org/10.1212/WNL.0000000000010649
Marta I. Bala
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Anibal Chertcoff
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Miguel Saucedo
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Fabio Gonzalez
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Luis A. Miquelini
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Pablo Bonardo
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Ricardo Reisin
From the Departments of Neurology (M.I.B., A.C., M.S., F.G., P.B., R.R.) and Neuroradiology (L.A.M.), Hospital Británico de Buenos Aires, Argentina.
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Teaching NeuroImages: Nonketotic hyperglycemic hyperosmolar state mimicking acute ischemic stroke
Marta I. Bala, Anibal Chertcoff, Miguel Saucedo, Fabio Gonzalez, Luis A. Miquelini, Pablo Bonardo, Ricardo Reisin
Neurology Nov 2020, 95 (18) e2600-e2601; DOI: 10.1212/WNL.0000000000010649

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A 55-year-old man with diabetes mellitus type 2 presented with persistent right homonymous hemianopia of 72 hours evolution. At admission, the laboratory examination revealed blood glucose of 497 mg/dL and hyperosmolality without ketosis; the EEG did not show epileptic discharges. EEG done during the following days did not show any abnormalities. Brain MRI showed a subcortical lesion on the left occipital lobe (figure). The patient’s symptoms and MRI abnormalities resolved after glucose-lowering treatment.

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Figure Occipital MRI changes in nonketotic hyperglycemic hyperosmolar state

On admission, brain MRI showed a left subcortical occipital lesion that was hypointense on fluid-attenuated inversion recovery, T2, susceptibility-weighted imaging, and apparent diffusion coefficient map (A–C and E) and hyperintense on diffusion-weighted imaging (D). A control brain MRI performed at 3 months was normal (F–H).

Nonketotic hyperglycemic hyperosmolar state is a condition associated with neurologic deficits that could mimic an acute ischemic stroke. The underlying mechanisms for MRI findings in this condition have not been fully elucidated, but it has been postulated that increased plasma osmolality with the subsequent development of hyperviscosity may lead to a hypoxic–ischemic insult resulting in the release of free radicals in the brain.1,2

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No targeted funding reported.

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The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

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Table1

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Teaching slides links.lww.com/WNL/B190

  • © 2020 American Academy of Neurology

References

  1. 1.↵
    1. Raghavendra S,
    2. Ashalatha R,
    3. Thomas SV,
    4. Kesavadas C
    . Focal neuronal loss, reversible subcortical focal T2 hypointensity in seizures with a nonketotic hyperglycemic hyperosmolar state. Neuroradiology 2007;49:299–305.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Strowd RE,
    2. Wabnitz A,
    3. Balakrishnan N,
    4. Craig J,
    5. Tegeler CH
    . Clinical reasoning: acute-onset homonymous hemianopia with hyperglycemia. Neurology 2014;82:e129–e133.
    OpenUrlAbstract/FREE Full Text

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