Dilemma in the emergency setting: hypomagnesemia mimicking acute stroke

Abstract

BackgroundStroke mimics may account for up to 30% of all acute stroke consultations. However, in the emergency setting, accurate diagnosis is not always possible.MethodsCase report and review of the literature.ResultsA 73-year-old woman was admitted to the emergency department with acute aphasia and right hemiparesis. The National Institute of Health Stroke Score was 21, compatible with severe stroke, so she received thrombolysis. Laboratory testing demonstrated severe hypomagnesemia. She had been taking proton pump inhibitors for years and neuroimaging did not demonstrate signs of acute ischemic disease. After correcting the metabolic alterations with intravenous and oral supplemental magnesium, the patient was discharged asymptomatic. No further episodes have been registered to date.ConclusionHypomagnesemia might cause acute neurological symptoms that could be confused with stroke. A careful history is essential for diagnosis but suspicion of stroke mimic should not prevent tPA administration.

Recommendation on an updated standardization of serum magnesium reference ranges

“…These clinical manifestations include metabolic issues (hypokalemia and hypocalcemia), neuromuscular-central nervous system symptoms (hyperexcitability, muscle weakness, tremors, seizures, tetany, headaches, and fatigue), cardiovascular abnormalities (tachycardia, arrhythmias such as torsade de pointes, ventricular fibrillation, mitral valve prolapse, cardiac ischemia, myocardial infarct, and hypertension), and endocrine abnormalities (insulin resistance and type 2 diabetes) [2,3] (Table 1). Reported severe, overt symptoms of hypomagnesemia also include the mimic of acute stroke [4], life-threatening arrhythmias [3], metabolic acidosis [5], and new-onset diabetes following heart transplantation [6]. In intensive-care units, hypomagnesemia is associated with higher mortality, the need for mechanical ventilation, and increased length of stay [7].…”

Severe hypomagnesaemia as new potential stroke mimic: a case report

“…Metabolic disorders, such as hypernatriaemia, hyponatriaemia, or hepatic encephalopathy, may also cause focal neurologic symptoms. To our knowledge, so far, only two clinical cases have been reported of hypomagnesaemia stroke-mimicking [ 1 , 2 ].…”

“…Even if it is quite rare, low levels of magnesium could mimic an acute stroke. Stroke-mimics represent about 30% of all acute stroke presentations [ 1 ], so it is important to rule them out as fast as possible. In conclusion, we suggest considering hypomagnesaemia a possible cause of a stroke mimic and including magnesium dosage in emergency blood tests, mainly in the presence of heavy smokers or patients with hypokalaemia or with a longstanding PPI(s) use.…”

Delayed neurologic sequelae of carbon monoxide intoxication

“…There is no effective treatment for delayed posthypoxic demyelination resulting from CO intoxication. 12 Serious CO intoxication is treated only with oxygen therapy. HBOT acts to increase oxygen partial pressure in the blood, decrease COHb tension, and improve tissue oxygenation.…”

“…15 Other experimental treatments have been evaluated in clinical trials, including anti-inflammatory and immunomodulatory agents such as immuneglobulin, interferon, glatiramer acetate, and steroids, but with limited success. 12 Hydrogen-rich saline has a lower hydroxyl radical concentration than water, has low toxicity, and is thought to be neuroprotective in ischemia-reperfusion injury. 14 Allopurinol reportedly protects against brain ischemia and oxidative-stress-induced reperfusion injury; it also decreases the severity of DNS by inhibiting xanthine oxidoreductase, which promotes free radical production during cerebral ischemia/reperfusion.…”