Hemiparesis and facial droop in an older woman
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-067134 (Published 13 January 2022) Cite this as: BMJ 2022;376:e067134
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Dear Editor,
The case review by Anyfantakis and Kastanakis is a very useful reminder of the need to consider hypoglycaemia as a cause of focal neurological symptoms of sudden onset and therefore as a mimic of stroke. I would however like to make the following comments:
1) The discussion contains an internal contradiction. The authors state "recognition of hypoglycaemia is essential...to avoid unnecessary investigations (brain CT) ..." but elsewhere state that "a CT scan of the brain is necessary to rule out transient ischaemic stroke".
2) If by transient ischaemic stroke the authors mean transient ischaemic attack (TIA), a CT scan would neither confirm nor rule out this diagnosis as it would by definition be normal. I acknowledge that some clinically defined TIAs turn out in retrospect to be minor completed ischaemic strokes, but these small lesions would be more readily detected by MRI scan than by CT.
3) I have no statistics available, but would suggest that malignant tumours of the cerebellopontine angle would be an exceedingly rare cause of focal neurological symptoms of sudden onset, certainly less common than hemiplegic migraine. Further, as a cause of neurological symptoms of gradual onset, I believe that benign tumours in this area (i.e., acoustic schwannomas) would be a good deal more common than malignant tumours, although it is true that these lesions may be benign only in a histological sense, being sometimes exceedingly difficult to treat.
Competing interests: No competing interests
Dear Editor,
CT won’t rule out a TIA. It would only have other uses.
Competing interests: No competing interests
Re: Hemiparesis and facial droop in an older woman
Dear Editor,
Hypoglycemia could be a reversible cause of focal neurological symptoms (1). We read with interest the three points raised by Dr Walsh (2) in response to our educational article (1).
We can see a point of apparent contradiction mentioned by the colleague, by isolating text parts written in a not native language. However, the early recognition of hypoglycemia and its correction will lead to prompt clinical improvement and symptom banishment, a fact that may render further investigations useless. Clinical decisions always have a time-event sequence dimension. On the other hand, brain CT imaging is necessary if symptoms persist, glycemic levels do not explain symptom occurrence or evolution and the dilemma between detectable or not detectable brain lesions cannot be answered without, at least, a first-line imaging choice decision, as a CT. We do not believe that there is any content ambiguity within.
Traditionally, brain CT represents the “workhorse” imaging investigation in clinical routine for the evaluation of acute stroke patients (3). Over the last years brain MRI is characterized by a higher diagnostic accuracy, since it provides better resolution of brain parenchyma fewer artefacts, permitting earlier detection of ischemic brain damage via diffusion-weighted imaging (DWI) (4). An interesting study by Moreau et al, compared the yield of acute ischemic lesions on MRI and CT in the diagnosis of TIA or minor stroke. Acute ischemic lesions were detected in 86% of minor strokes by using MRI versus 18% by using CT (5). Acute ischemic lesions were detected in 39% of TIAs by using MRI versus 8% by using CT. CT had a sensitivity of 20% and a specificity of 98% in identifying an acute ischemic lesion (5).
So we agree a priori with this comment. A CT will identify 20% of patients who truly have an acute ischemic lesion. Half of the patients who were negative on CT had evidence of an acute lesion on MRI and the lesions missed by CT but identified by MRI had a smaller infarct volume (5). Neurological symptom persistence or complete resolution deserves careful assessment for further decisions. MRI can fairly offer a further insight, as a following stage investigation to be more than plausible as choice.
We have no reason to argue with the colleague's third point either. A clinician should have in mind both malignant and benign lesions at specific brain anatomical areas. In our patient, the complete symptom resolution due to the glycemic correction and afterwards the patient’s uneventful recovery led us to think that a neoplastic lesionis is not likely to be cause of this transient clinical manifestation.
Competing interests: None
References
1. Anyfantakis D, Kastanakis S. Hemiparesis and facial droop in an older woman. BMJ. 2022 Jan 13;376:e067134. doi: 10.1136/bmj-2021-067134.
2. Walsh K. Re: Hemiparesis and facial droop in an older woman. XXX
3. Kaste M. Reborn workhorse, CT, pulls the wagon toward thrombolysis beyond 3 hours. Stroke. 2004; 35(2):357-9. doi: 10.1161/01.STR.0000115165.43847.
4. Diaconis JN, Rao KC. CT in head trauma: a review. J Comput Tomogr. 1980 ; 4(4):261-70. doi: 10.1016/0149-936x(80)90018-1.
5. Moreau F, Asdaghi N, Modi J, Goyal M, Coutts SB. Magnetic Resonance Imaging versus Computed Tomography in Transient Ischemic Attack and Minor Stroke: The More Υou See the More You Know. Cerebrovasc Dis Extra. 2013;3(1):130-136. doi:10.1159/000355024
Competing interests: No competing interests