Neuroimaging findings in acute pediatric diabetic ketoacidosis

Abstract

Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency and a serious complication in children with diabetes mellitus type 1. In a small number of children, DKA is complicated by injury of the central nervous system. These children have a significant mortality and high long-term neurological morbidity. Cerebral edema is the most common neuroimaging finding in children with DKA and may cause brain herniation. Ischemic or hemorrhagic stroke during the acute DKA episode is less common and accounts for approximately 10% of intracerebral complications of DKA. Here we present the neuroimaging findings of two children with DKA and brain injury. Familiarity with the spectrum of neuroimaging findings seen in pediatric DKA is important to allow early detection as well as initiation of therapy and, hence, prevent complications of the central nervous system.

Keywords: Diabetic ketoacidosis; MRI; brain; children; stroke.

Figure 1.

((a)–(c)) Acute axial CT images of patient 1 show diffuse cerebral edema with hypodense brain parenchyma and effacement of sulci and basal cisterns. CT: computed tomography.

Figure 2.

((a), (b)) Follow-up axial T2-weighted MR images, ((c), (d)) trace of diffusion images and ((e), (f)) ADC maps of patient 1 performed one week after the CT (Figure 1) show T2-hyperintense signal with matching bright signal on trace of diffusion and low ADC values within the left posterior lateral aspect of the pons, left posterior limb of the internal capsule, bilateral anterior medial thalami, and genu of the corpus callosum. In addition, focal areas of T2-hyperintense signal with matching high ADC values are seen within the left inferior olivary nucleus, left paracentral posterior pons, left side of the posterior lateral thalamus, right posterior limb of internal capsule, right genu of the internal capsule, and bilateral medial thalamus. MR: magnetic resonance; ADC: apparent diffusion coefficient; CT: computed tomography.

Figure 3.

((a), (b)) Acute axial CT images of patient 2 show diffuse effacement of the sulci and basal and suprasellar cisterns suggestive of global cerebral edema. In addition, a cortical/subcortical hypodensity is noted within the vascular territory of the left posterior cerebral artery concerning for an acute/subacute ischemic stroke. CT: computed tomography.

Figure 4.

((a), (b)) Axial T2-weighted MR images, ((c), (d)) trace of diffusion and ((e), (f)) ADC maps of patient 2 performed the subsequent day compared to the CT (Figure 3) reveal T2-hyperintense signal with matching bright signal on trace of diffusion images and reduced ADC values within the vascular territory of the left posterior cerebral artery confirming the acute/subacute arterial ischemic stroke. In addition, T2-hyperintense foci with restricted diffusion are seen within the medial thalami bilaterally, midbrain, bilateral amygdala, posterior inferior aspect of bilateral frontal lobes, and left medial temporal lobe. The last ones are most likely secondary to transtentorial herniation. MR: magnetic resonance; ADC: apparent diffusion coefficient; CT: computed tomography.