Diabetic ketoacidosis-associated stroke in children and youth

Abstract

Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency, either absolute or relative, resulting in hyperglycemia and ketonemia. Although possibly underappreciated, up to 10% of cases of intracerebral complications associated with an episode of DKA, and/or its treatment, in children and youth are due to hemorrhage or ischemic brain infarction. Systemic inflammation is present in DKA, with resultant vascular endothelial perturbation that may result in coagulopathy and increased hemorrhagic risk. Thrombotic risk during DKA is elevated by abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. DKA-associated cerebral edema may also predispose to ischemic injury and hemorrhage, though cases of stroke without concomitant cerebral edema have been identified. We review the current literature regarding the pathogenesis of stroke during an episode of DKA in children and youth.

Figure 1

White matter hemorrhages associated with DKA. (a) This low-power view of a gyrus (stained with hematoxylin, eosin, and Luxol fast blue) illustrates multiple small and microscopic hemorrhages (arrowheads) associated with “confluent” pallor (asterisks) of the myelin, a thin layer of preserved subcortical myelin (arrows), and normal cortex. (b) A vessel, labeled V, is identified for reference. Stained with Luxol fast blue, hematoxylin, and eosin (which stains myelin blue). Central hemorrhage was formed by perivascular necrosis (arrow), a concentric ring of red blood cells, and diffusely rarefied white matter that is speckled with eosinophilic astrocytes (arrowheads). Figure 1 reproduced with permission from Pediatrics, volume 126, page 1543, copyright 2007 by the AAP.,