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Case report
Facial twitching: calcium or concussion conundrum? Hypocalcaemia in a young American football player masking an internal carotid artery dissection
  1. Seethalakshmi Muthalagappan1,
  2. Timothy Robbins2,
  3. Hiten Mehta3 and
  4. Narasimha Murthy2
  1. 1Diabetes and Endocrinology, South Warwickshire NHS Foundation Trust, Warwick, UK
  2. 2Diabetes and Endocrinology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
  3. 3Radiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
  1. Correspondence to Dr Timothy Robbins; drtrobbins{at}


A 30-year-old male American football player presented to the acute medical unit with left-hand and hemifacial spasms. History and examination revealed hemifacial spasms in keeping with seizure-like activity possibly due to symptomatic hypocalcaemia. Subsequent investigations revealed an adjusted calcium of 1.87 mmol/L and, hence, he was managed with intravenous calcium replacement. He presented two further times in a 1-month period, with subjective limb weakness, despite normal adjusted calcium. During his third admission, he developed slurred speech and a marked facial droop, with absence of power in the right upper limb. Imaging revealed acute and old infarctions in the left middle cerebral artery territory and appearances consistent with left internal carotid artery dissection. This presentation of arterial stroke is atypical but with potentially grave consequences if missed. There is limited literature on the presentation of hemifacial spasm, and its association with ischaemic or haemorrhagic stroke represents a key learning point.

  • stroke
  • calcium and bone

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  • Contributors All authors contributed to the development of this case report. SM and NM were involved in the initial management of the patient when he attended the hospital, alongside initial preparation for production of the case report. SM and TR wrote the case report through multiple revisions supported by NM as supervising consultant. NM and TR discussed the case report with the patient and arranged for the consent form to be completed. HM provided considerable support in the revision of the manuscript, including neuroradiology input.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.