Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis

Abstract

Symptomatic cerebral edema occurs in approximately 1% of children with diabetic ketoacidosis (DKA). However, asymptomatic or subclinical cerebral edema is thought to occur more frequently. Some small studies have found narrowing of the cerebral ventricles indicating cerebral edema in most or all children with DKA, but other studies have not detected narrowing in ventricle size. In this study, we measured the intercaudate width of the frontal horns of the lateral ventricles using magnetic resonance imaging (MRI) in children with DKA during treatment and after recovery from the DKA episode. We determined the frequency of ventricular narrowing and compared clinical and biochemical data for children with and without ventricular narrowing. Forty-one children completed the study protocol. The lateral ventricles were significantly smaller during DKA treatment (mean width, 9.3 +/- 0.3 vs. 10.2 +/- 0.3 mm after recovery from DKA, p < 0.001). Children with ventricular narrowing during DKA treatment (22 children, 54%) were more likely to have mental status abnormalities than those without narrowing [12/22 vs. 4/19 with Glasgow Coma Scale (GCS) scores below 15 during therapy, p = 0.03]. Multiple logistic regression analysis revealed that a lower initial PCO2 level was significantly associated with ventricular narrowing [odds ratio (OR) = 0.88, 95% confidence interval (95% CI) = 0.78-0.99, p = 0.047). No other variables analyzed were associated with ventricular narrowing in the multivariate analysis. We conclude that narrowing of the lateral ventricles is evident in just over half of children being treated for DKA. Although children with ventricular narrowing did not exhibit neurological abnormalities sufficient for a diagnosis of 'symptomatic cerebral edema', mild mental status abnormalities occurred frequently, suggesting that clinical evidence of cerebral edema in children with DKA may be more common than previously reported.

Hypophosphatemia-Induced Seizure in a Child With Diabetic Ketoacidosis

“…On the other hand, imaging studies showing lateral ventricular narrowing in children with DKA indicate that some degree of cerebral edema may be present even in patients without significant clinical evidence of this complication. 19,20 In our view, the hypothesis that the seizure was triggered by hypophosphatemia is supported by the clinical improvement seen after the correction of this electrolytic disturbance, in the absence of any other etiology. The fact that hypophosphatemia occurred during the resolution phase of DKA and that the child was awake and being fed may have contributed to the underestimation of the severity of the diagnosis.…”

Predictors of Altered Sensorium at Admission in Children with Diabetic Ketoacidosis

“…A study by Fulop et al attributed altered sensorium in adult DKA patients to the effect of hyperglycemia and hyperosmolarity and concluded that depth of stupor parallels the intensity of hyperglycemia and hyperosmolarity and not acidemia [10]. Whereas Glaser et al postulated that range of sensorial abnormalities in DKA could be explained by mild cerebral edema, which was evidenced by narrowing of the lateral cerebral ventricles on MRI in the study [12]. Children with mild cerebral edema did not have overt signs of symptomatic cerebral edema, but mild mental status abnormalities were noted by them.…”

Subclinical Cerebral Edema in Children With Diabetic Ketoacidosis Randomized to 2 Different Rehydration Protocols

“…[8][9][10] This subclinical CE can be demonstrated by using various techniques, including magnetic resonance diffusion weighted imaging (DWI). 4,11 DWI quantifies the diffusion of water molecules in brain tissues and is reported as the apparent diffusion coefficient (ADC).…”