Atypical Hypoglycemia-Induced Stroke Mimic: A Case Report and Literature Review

This case describes an uncommon presentation of a hypoglycemia-related stroke mimic in a patient with poorly controlled type 2 diabetes, in whom acute neurological symptoms developed despite a blood glucose level above the conventional hypoglycemic threshold. A 72-year-old woman presented with acute fatigue, drowsiness, and dysarthria after initiation of an intensified glucose-lowering regimen. Her blood glucose level was 4.1 mmol/L at symptom onset and increased after glucose administration; however, her neurological symptoms persisted. Because acute ischemic stroke could not be confidently excluded during the emergency evaluation, intravenous alteplase was administered. Her symptoms subsequently improved approximately 9.5 hours after symptom onset. Comprehensive neurovascular and brain imaging, including computed tomography, computed tomography angiography, magnetic resonance imaging, and transcranial Doppler ultrasonography, showed no evidence of acute ischemic lesions or significant vascular occlusion. After adjustment of her glucose-lowering therapy, her neurological condition remained stable, and no permanent neurological deficits were observed. This case highlights the diagnostic challenge of distinguishing hypoglycemia-related stroke mimic from acute ischemic stroke, particularly in patients with poorly controlled diabetes and fluctuating glucose levels. It also suggests that relative or rapidly declining glucose levels may contribute to stroke-like neurological symptoms even when absolute glucose values do not meet the conventional definition of hypoglycemia. Careful clinical assessment, timely glucose measurement, and urgent stroke evaluation remain essential when acute ischemic stroke cannot be reliably excluded.