Initial Management of Acute Metabolic Encephalopathy Presenting with Stroke-like Symptoms

Initial Assessment and Stabilization

• The American Heart Association recommends immediately assessing and stabilizing airway, breathing, and circulation (ABCs), as with any critically ill patient 2, 3
• The American Heart Association suggests performing rapid neurological examination to assess focal deficits and level of consciousness 2, 3
• Obtain immediate point-of-care glucose measurement, as hypoglycemia is a common and rapidly reversible cause of stroke-like symptoms 4
• Correct hypoglycemia (low blood glucose) immediately with intravenous glucose administration 5, 4
• Administer supplemental oxygen if oxygen saturation is low as measured by pulse oximetry 6, 4

Urgent Laboratory Testing

• Order immediate blood work including complete blood count 7
• Obtain blood glucose (if not already obtained via point-of-care testing) 4
• Measure serum osmolality 5
• Consider toxicology screen if drug toxicity is suspected 6

Neuroimaging

• Obtain urgent non-contrast CT scan of the brain to exclude hemorrhage and assess for other structural causes 1, 2
• Consider MRI with diffusion-weighted imaging if initial CT is negative but clinical suspicion for stroke remains high 2, 3

Management of Common Metabolic Causes

• Correct low blood glucose with intravenous glucose administration 5, 4
• Treat significant high blood glucose with careful insulin administration 5, 4
• Maintain euvolemia with isotonic fluids (0.9% saline) rather than hypotonic solutions 5
• Administer thiamine in patients with suspected Wernicke's encephalopathy 3

Differentiating from Acute Ischemic Stroke

• Use the American Heart Association/American Stroke Association guidelines to identify stroke mimics 2, 3

• Consider the following stroke mimics:

  Condition	Characteristics
  Hypoglycemia	History of diabetes, low serum glucose, decreased level of consciousness [1]
  Hypertensive encephalopathy	Headache, delirium, significant hypertension [1]
  Wernicke's encephalopathy	History of alcohol abuse, ataxia, ophthalmoplegia, confusion [1]
  Drug toxicity	Especially from certain medications [2]

• Avoid hypotonic fluids in patients with suspected metabolic encephalopathy as they may exacerbate cerebral edema 5