Spontaneous intracerebral hematomas in juvenile diabetic ketoacidosis

Diabetic Ketoacidosis-Induced "Terrible Triad" Associated With Seizures and Acute Renal Failure: A Report of a Rare Case

We report a case of a 17-year-old male patient who came to the emergency department with abdominal pain, headaches for two days, lethargy, and Kussmaul breathing. Diabetic ketoacidosis (DKA) was diagnosed. The patient's clinical course was complicated with a severely elevated triglyceride (TG) level (25,585 mg/dL), acute pancreatitis, renal involvement, and generalized seizures. The proposed mechanism is triglyceride excess due to increased lipolysis, resulting in the formation of excess free fatty acids. The objective of this case report is to present and describe the clinical features, laboratory investigations, case management, and natural course of hypertriglyceridemia in DKA.

Hemorrhagic stroke: Uncommon complication of diabetic ketoacidosis in pediatric patients

Diabetic ketoacidosis (DKA) is a well-known complication of type 1 diabetes mellitus. Diabetic ketoacidosis predisposes patients into devastating neurological complications. The most common neurologic complication is cerebral edema. Stroke either ischemic or hemorrhagic are uncommon complications of DKA with worse patient's outcome. Hemorrhagic stroke can manifest as subarachnoid or intraparenchymal hemorrhage. We present a 14-year-girl presented with DKA and complicated with both subarachnoid and intraparenchymal hemorrhages. Owing to early diagnosis and prompt treatment the patient had good outcome.

Multiple Spontaneous Intracerebral Hematoma without Presenting Risk Factors

The incidence of intracerebral hemorrhage in those aged 45–84 years is 0.3-0.5%. In people over 80 years of age, this incidence increases 25-fold compared with that of the total population. The most common causes of spontaneous intracerebral hemorrhage in the younger population are vascular malformation, aneurysm, and overuse of drugs. In contrast, common causes in the elderly include hypertension, tumors, and coagulation disorders. Here, we present a case involving a 72-year-old male patient who, without any of these predisposing conditions, was admitted to the hospital with spontaneous intracerebral hemorrhage and showed signs of multifocal intracerebral hemorrhage during his stay. We conclude that spontaneous intracerebral hemorrhage can occur without any predisposing factors, and can lead to a patient's death. Therefore, the possibility of recurrent spontaneous intracerebral hemorrhage must be considered in patients with primary spontaneous intracerebral hemorrhage.

Diabetic ketoacidosis with cerebral hemorrhage and alpha coma in an adolescent female

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most common and harmful complications of type 1 diabetes in children. The neurologic morbidities, including seizure activity, motor/sensory deficit, and coma, can be seen secondary to cerebral edema, hemorrhage, or ischemia. Alpha-frequency is a normal 8-13 Hz physiologic electroencephalogram rhythm that is seen most prominently in the occipital region of awake people and is augmented by eye closure. In the comatose patient, alpha-rhythm is not usually seen. Alpha-frequency coma (AC) is a rare finding in comatose patients and is generally associated with a poor prognosis.

CASE REPORT

We report an adolescent with severe DKA, intraparenchymal cerebral hemorrhage, and AC, who had a rapid resolution of the neurologic symptoms.

CONCLUSIONS

Similar to other reported cases, our case suggests that the prognosis for patients with AC may not be always poor when it is associated with DKA.

Diabetic ketoacidosis-associated stroke in children and youth

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.

Occult infarct with acute hemorrhagic stroke in juvenile diabetic ketoacidosis

Diabetes ketoacidosis (DKA) is one of the common complications of type I insulin-dependent diabetes mellitus. Neurological deterioration during an episode of DKA is usually assumed to be caused by cerebral edema and cerebral vascular accidents. However, hemorrhagic stroke is a very rare complication of juvenile DKA. We describe a girl who had newly diagnosed insulin-dependent diabetes mellitus with juvenile DKA developed intracerebral hemorrhage.

Occurrence of diabetes mellitus in spontaneous intracerebral hemorrhage

The role of diabetes mellitus (DM) in the etiopathogenesis of spontaneous intracerebral hemorrhage (SICH) is controversial. The aim was to assess the role of DM in our SICH patients. In a hospital-based cross-section study, the occurrence of DM prior to a hemorrhagic stroke was observed in 80 SICH patients (44 males, aged 36-87 years, mean 67.1 +/- 11.9 years; 36 females, aged 56-86 years, mean 71.1 +/- 8.3 years), and in a control group (CG) of 80 age- and sex-matched patients with low back pain. All patients were treated at the Departments of Neurology and Neurosurgery, University Hospital, Olomouc, Czech Republic. Two-sample t test and Pearson's homogeneity chi(2) test were applied when assessing statistical significance. DM was found in 37.5% of SICH patients versus 22.5% of CG subjects (P < 0.05). DM occurs significantly more frequently in SICH patients in the Olomouc region of the Czech Republic when compared to the general population.

Coma with diffuse white matter hemorrhages in juvenile diabetic ketoacidosis

Cerebral edema is the most common neurologic complication of diabetic ketoacidosis in children. A minority of young patients with intracerebral crises in diabetic ketoacidosis present with cerebrovascular accidents. We report 2 adolescent patients with diabetic ketoacidosis who presented with coma and diffuse white matter hemorrhages in the absence of either cerebral edema or cerebrovascular accidents. These 2 cases illustrate a novel clinical and neuropathologic description of diffuse white matter hemorrhages, possibly related to a cytotoxic process as the underlying mechanism. These case descriptions emphasize that pediatric patients with diabetic ketoacidosis and coma can present with pathology not related to either cerebral edema or cerebrovascular accidents.

Characteristics at diagnosis of type 1 diabetes in children younger than 6 years

OBJECTIVE

To characterize the prodrome, presentation, family history, and biochemical status at diagnosis of type 1 diabetes mellitus (T1D) in children under age 6 years.

STUDY DESIGN

This was a retrospective chart review of patients hospitalized at diagnosis with T1D from 1990 to 1999 in a children's hospital.

RESULTS

A total of 247 children were hospitalized, 44% of whom presented in diabetic ketoacidosis (DKA). When stratified by 2-year age intervals, only total carbon dioxide (tCO(2)) was significantly lower in the youngest children (P = .02), and the duration of candidiasis was significantly longer in those children presenting in DKA (P = .004). Parents were more likely to recognize symptomatic hyperglycemia in children older than 2 years (P < .0001). Most parents sought care for their child suspecting that the child had diabetes; the other children were diagnosed when presenting with another concern. Only gender and tCO(2) were significantly correlated with hemoglobin A1c (HbA1c); age-adjusted HbA1c was 0.64% higher in girls compared with boys (P = .045), and each 1-mmol/L decrement in tCO(2) increased the age- and gender-adjusted HbA1c by 0.086% (P < .001).

CONCLUSIONS

A high proportion of children under age 6 years present critically ill at the diagnosis of T1D. When any of the classic symptoms of diabetes or a yeast infection is present, a serum glucose level should be measured.

ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.

Cerebral oedema during treatment of diabetic ketoacidosis: are we any nearer finding a cause?

Cerebral oedema remains the leading cause of death and morbidity in children with Type 1 diabetes mellitus. Around seven per thousand episodes of diabetic ketoacidosis (DKA) are complicated by cerebral oedema, and one-quarter of those children will die from it. The cause or causes of cerebral oedema are still very poorly understood, but lawyers are already keen to implicate various aspects of the management of DKA. There have been many theories as to the pathophysiology of cerebral oedema, and possible contributing factors may be excessive rate of rehydration, falling plasma osmolality (particularly that due to a reduction in plasma sodium concentration), hypoxia and insulin dosage. There is some supportive evidence for all of these factors in some cases, but there have been no sizeable case-control studies, in part because of the rarity of the condition. Furthermore, cerebral oedema can still occur even when the management of DKA follows current 'best practice' guidelines. As the mechanisms of cell volume regulation within the brain are increasingly understood, different questions may provide greater insights. For example, what is it about children that makes them so much more susceptible to cerebral oedema than adults? And why does one child treated in a certain way develop cerebral oedema whereas another does not? The anxiety over causing cerebral oedema has driven most of the changes in the management of DKA over recent decades, yet there is no evidence that the incidence has reduced. Until the causes are understood, we cannot be dogmatic about treatment recommendations.

Diabetes and the nervous system

Hyperglycemia and its vascular complications affect the entire nervous system, contributing to increased morbidity and mortality. Chronic hyperglycemia is not only a known and major risk factor for cerebral vascular diseases but also the presence of hyperglycemia at the time of a cerebrovascular event may adversely influence the outcome. It also affects the treatment of some neurodegenerative disorders, and there are suggestions that diabetes may in fact suffer from a "chronic diabetic encephalopathy." Its varied effects on the peripheral nervous system result in several forms of diabetic neuropathies, the exact pathogenesis of which is still obscure. There is, however, some new information that may link metabolic and vascular hypotheses.

Transcranial Doppler ultrasound assessment of intracranial hemodynamics in children with diabetic ketoacidosis

The pathophysiology of acute neurological complications of diabetic ketoacidosis (DKA) in children and adolescents is not completely understood. We sought to establish whether transcranial Doppler (TCD) was able to monitor the changes of cerebral blood flow regulatory mechanisms, as measured by cerebral blood velocities (CBF-V), Gosling's pulsatility index (PI), and cerebral vascular reactivity (VR), prior to and during treatment of DKA. The increased values of PI suggested an increase of intracranial pressure (ICP) due to the existence of cerebral vasoparalysis, based on the low values of VR prior to treatment and 6 hours after initiation of treatment. At 24 hours, the correction of hematocrit and pH was associated with a significant decrease of PI, suggesting a decrease of ICP, likely due to a return of vascular tone in response to the low PaCO2. This was further supported by an increase of VR in all patients. At 48 hours, when PaCO2 returned to normal, the PI remained low and the VR increased further, suggesting a complete reversal of vasoparalysis and a return of cerebral blood flow regulatory mechanisms.

Multiple cerebral haematomata and peripheral nerve palsies associated with a case of juvenile diabetic ketoacidosis

A 15-year-old girl presented de novo in diabetic ketoacidosis having been comatose for 24 h (day 1). A CT scan and lumbar puncture performed on admission were normal and her conscious level slowly improved over several days. On day 7 she had central neurological signs of bilateral knee clonus and an extensor plantar response. In addition, she had developed lower motor neurological signs of an ulnar nerve palsy of the left forearm, and ulnar, median, and radial nerve palsies of the right forearm. Magnetic resonance imaging (MRI), performed on day 12, showed multiple small cerebral haematomata with appearances at least several days of age. The scattered lesions were localized particularly to the parieto-occipital region, with sparing of the basal ganglia and without cerebral oedema, a novel feature not previously described in juvenile ketoacidosis. Four months later there was minimal residual disability of her right arm. The clinical findings together with the MRI images suggested that the peripheral nerve and central lesions were temporally related, suggesting a common aetiology. However, it is likely that MRI showed cerebral lesions which may have been missed by the conventional CT scanning performed initially.

Diabetes and stroke

Diabetes is a major risk factor for development of ischemic cerebrovascular disease. Patients with diabetes are at least two times more likely to have a stroke than nondiabetics. In addition, they are more likely to suffer increased morbidity and mortality after stroke. The mechanism of production of stroke secondary to diabetes may be due to cerebrovascular atherosclerosis, cardiac embolism, or rheologic abnormalities. The evaluation of cerebrovascular disease in diabetic patients is similar to the nondiabetic patient, with particular attention paid to adequate hydration prior to the administration of contrast agents. Treatment options for stroke in diabetics requires individualization but should include risk factor modification, and may include platelet antiaggregants, anticoagulation, or, in a well-defined subgroup, carotid endarterectomy.

Diabetic Ketoacidosis: Pathophysiology, Management and Complications

Diabetic ketoacidosis (DKA) is a common and potentially life-threatening complication of diabetes mellitus, the second most common chronic childhood disease [1]. Prior to the introduction of insulin to clinical medicine by Banting and Best in 1922, DKA had a mortality rate greater than 60% [2]. As insulin was introduced into clinical practice, there was a gradual decrease in mortality associated with DKA over the subsequent 30 years. Recent epidemiological data reveal current mortality varies from 0 to 19% [3,4]. DKA continues to be the most common cause of death in patients younger than 24 years of age; it accounts for as many as 50% of deaths of young diabetic patients [5–7]. In elderly diabetics who have coexisting diseases, DKA carries a high mortality [8]. Despite many advances in the care of diabetic patients, the prevalence of DKA is not declining; it accounts for 14% of all diabetes-related hospital admissions [3, 4, 9].

The incidence of insulin-dependent diabetes mellitus continues to increase worldwide and has roughly doubled in each recent decade [10–13]. Because insulin-dependent diabetes mellitus is increasing, and preventative measures to avoid DKA in diabetic patients have not been successful, the incidence of DKA can also be expected to increase in coming years. Prevention of DKA is the ultimate goal (80% of hospital admissions for DKA occur in treated diabetics) [3,8]. It is necessary for clinicians to understand the pathophysiology and treatment of DKA to care for this increasing diabetic population. We discuss the pathophysiology of diabetic ketoacidosis, its management, and its complications.