Diabetic Ketoacidosis-Associated Stroke in Children and Youth

Table 1

Case reports of arterial ischemic stroke, cerebral venous thrombotic stroke, and hemorrhagic stroke associated with an episode of DKA in children and youth.

Patient number	Age (year)	Gender	Pathologic findings	Clinical Presentation	Outcome	Coagulation profile	Reference number
Arterial Ischemic Stroke.
1	0.25	female	Multiple small vessel thrombi with edema on autopsy	First presentation diabetes, generalized seizure, progressive coma on admission	Death at 24 hours		[13]
2	4	female	Infarction, right posterior cerebral artery distribution	First presentation diabetes, decerebrate posturing, acute herniation	Slowly regained ability to walk and comprehend speech	Low protein C normalized with treatment, elevated Factor VIII-vWF complex, elevated plasma and platelet thromboxane B2	[14]
3	8	male	Infarction of left thalamus, left temporal lobe, B/L occipital lobes	Decerebrate posturing	Slow recovery	Low protein C antigen, normalized	[14]
4	10	unknown	Basilar artery thrombosis on CT	Restless, decreasing LOC over 4.5 hours, respiratory arrest at 7 hours	Persistent vegetative state		[4]
5	14	female	CT edema and infarction of left lentiform nucleus, thalami, B/L peduncles	Headache, deteriorating LOC. Pupils midline, fixed, dilated after 12 hours	Mild left hemiparesis, behavioral disturbances		[15]
6	5	male	Infarction left posterior cerebral artery distribution, geniculate nuclei, left thalamus	First presentation diabetes, generalized seizure	Moderate left hemiplegia	Low protein S, elevated factor VIII and factor V	[5]
7	6	male	Infarction B/L anterior cerebral artery distributions, basal ganglia, left cingulate gyrus	First presentation diabetes, lethargy and posturing of upper extremities	Emotionally labile, intellectual and motor impairment	Low AT III antigen, AT III functionally normal, increased platelet aggregation	[5]
8	7	male	Ischemia in globus pallidus, B/L cingulate gyri. Infarctions left thalamus, right medial occipital lobe. No CT edema	First presentation diabetes, decreased level of consciousness with incontinence, stiffness, pupils poorly reactive	Hemiplegia, normal cognition, abnormal behavior and affect,	Decreased platelet aggregation	[5]
9	8	male	Infarction thalamus, midbrain, basal ganglia, cingulated gyrus. No CT edema	First presentation diabetes, unresponsive, flaccid, pupils dilated	Vegetative state	Low aPTT (21 seconds)	[5]
10	10	male	Infarction right anterior cerebral artery distribution, left putamen, B/L globus pallidus	First presentation diabetes, decreased LOC, left extensor posturing, abnormal papillary response	Severe focal neurologic impairment		[5]
11	6	female	Infarction proximal left middle cerebral artery, left basal ganglia	First presentation diabetes, irritability, lethargy, right hemiparesis, aphasia. Had 2 mitral valve thrombi	Regained speech, residual right hemiparesis	Normal pro-thrombotic studies	[6]
12	18	female	Infarction right common carotid artery territory with distal emboli in right anterior and middle cerebral arteries	First presentation diabetes, left hemiparesis 10 hours after carotid artery puncture	Moderate clinical recovery		[16]
Cerebral Venous Thrombosis.
13	5	female	Thrombosis of straight sinus and vein of Galen. Infarction of basal ganglia, thalamus	Confusion, decreased LOC, rigidity, fisting. Significant iron deficiency anemia	Mild learning difficulties	Normal clotting screen and thrombophilia screen	[17]
14	11	male	Multiple areas of infarction on MRI without hemorrhage or edema	Headache, nausea and vomiting, acute deterioration with fixed, dilated pupils. Had DVT of right superficial femoral and popliteal veins	Brain death	Decreased protein C function (36%), normal protein S and factor VIII, no anticardiolipins. Heterozygous factor V Leiden	[18]
15	19	female	Superior sagittal sinus thrombosis	First presentation diabetes. Anxiety progressed to psychosis, dysphasia, left abducens palsy, right inferior facial palsy, tetraparCsis with upper motor neuron signs	Partial left abducens paresis with diplopia which resolved	coagulopathy screen negative	[19]
16	8	male	Vein of galen and superior sagittal sinus thrombosis. B/L medial cerebral hemisphere infarctions	First presentation diabetes, loss of consciousness, sluggish pupillary reaction, fever	GCS remained 6 when transferred to another hospital	Low platelets, decreased ATIII (60.4%) increased with treatment, elevated D-dimer, increased with treatment	[20]
17	1.1	female	Left transverse sinus thrombosis, no infarction	First presentation of thiamine-responsive megaloblastic anemia, associated with nonimmune insulin-dependent diabetes. Right-sided focal seizure	Normal neurologic status	Prothrombotic screening negative	[16]
18	10	female	Thrombosis of superior sagittal, straight, right transverse, right sigmoid and proximal posterior left transverse sinuses	Headache, 6th cranial nerve palsy day 3, decreased level of consciousness day 5	Recombinant tPA thrombolysis, complete recovery	Heterozygous mutation of the prothrombin gene (G20210A)	[21]
Hemorrhagic infarction.
19	11	female	Multiple large, B/L posterior temporal lobe hematomas	Behavioral disturbance, lethargy, progressed to unresponsive, pupils dilated and unreactive	Normal neurologic exam		[22]
20	1	unknown	Subarachnoid hemorrhage on CT	Sudden respiratory arrest	Died at 2 days		[4]
21	11	unknown	Subarachnoid hemorrhage on CT	Progressively worsening neurologic status	Death		[4]
22	6.5	unknown	CT suggestive of subarachnoid hemorrhage	Severe headache and restless. Pupils fixed, dilated at 3 hours, respiratory arrest at 6 hours	Death		[4]
23	9	female	Hemorrhagic infarction right caudate nucleus, anterior limb of internal capsule. Non-hemorrhagic infarction of B/L thalami with edema	Ataxia, deteriorating LOC, abnormal respiratory pattern,. Developed decorticate posturing, right-sided tonic seizure	Communication disorder, asymmetric spastic quadriparesis, behavior disturbances.		[15]
24	9	female	Edema and hemorrhagic infarctions basal ganglia, upper brain stem, medial temporal lobes, frontal lobes, occipital lobes	Decreased LOC, left exotropia, unequal and unreactive pupils, papilledema	Quadriplegia, absent oculocephalic reflexes, central right facial paresis, profound cognitive defects		[15]
25	15	female	No cerebral edema in first 24 hours on CT. Multiple small hematomas, mainly parieto-occipital, on day 12 MRI	First episode diabetes. Significant hypotension, unconscious at presentation. Neurologically normal day 4. Bilateral knee clonus, extensor plantar response and peripheral nerve palsies on day 7		Decreased platelets (85,000), normal coagulation profile	[23]
26	11	female	Normal MRI. On autopsy: pin-point hemorrhages with ring-and-ball morphology in hemispheric white matter, throughout brainstem and spinal cord	First presentation diabetes, Hypotension, rapid deterioration in LOC	Death from renal complications	Normal coagulation studies	[24]
27	14	female	Petechial hemorrhages in B/L subcortical white matter U fibers, genu of corpus callosum, posterior limb of internal capsule, frontal lobe on MRI	First presentation diabetes, significant hypotension. Unresponsive and dyspneic	Short term memory loss, moderate cognitive deficits	Normal coagulation studies	[24]
28	5	female	Hemorrhagic infarct left thalamus	First presentation diabetes. Right central facial palsy, right hemiplegia, right babinski sign on day 7 of treatment	Mild learning difficulties	normal bleeding studies, normal protein C and S at time of hemorrhage	[25]

LOC: level of consciousness; B/L: bilateral; tPA: tissue plasminogen activator.