Cerebral Edema in Childhood Diabetic Ketoacidosis

Cerebral Edema in Childhood Diabetic Ketoacidosis Natural history, radiographic findings, and early identification Andrew B. Muir , MD 1 , Ronald G. Quisling , MD 2 , Mark C.K. Yang , PHD 3 and Arlan L. Rosenbloom , MD 1 1 Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida 2 Department of Radiology, University of Florida College of Medicine, Gainesville, Florida 3 Department of Statistics, University of Florida College of Medicine, Gainesville, Florida Address correspondence and reprint requests to Andrew Muir, MD, 1120 15th St., BG-1020, Augusta, GA 30912. E-mail: amuir{at}mcg.edu Abstract OBJECTIVE —Children who develop cerebral edema (CE) during diabetic ketoacidosis (DKA) exhibit definable signs and symptoms of neurological collapse early enough to allow intervention to prevent brain damage. Our objective was to develop a model for early detection of CE in children with DKA. RESEARCH DESIGN AND METHODS —A training sample of 26 occurrences of DKA complicated by severe CE and 69 episodes of uncomplicated DKA was reviewed. Signs of neurological disease were incorporated into a bedside evaluation protocol that was applied to an independent test sample of 17 patients previously reported to have developed symptomatic CE during treatment for DKA. Head computed tomograms and their reports were reviewed. RESULTS —The protocol allowed 92% sensitivity and 96% specificity for the recognition of CE sufficiently early for intervention. The diagnostic criteria were fulfilled in two temporal patterns, defining early- and late-onset CE. Although initial computed tomograms were often normal, the findings also included diffuse CE and focal brain injury, the latter only in patients with an early onset of abnormal neurological signs. CONCLUSIONS —CE may occur in the absence of acute changes on head computed tomograms. Early detection of CE at the bedside using an evidence-based protocol permits intervention in time to prevent permanent brain damage. CE, cerebral edema CT, computed tomography DKA, diabetic ketoacidosis ROC, receiver-operating characteristic Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted April 1, 2004. Received December 12, 2003. DIABETES CARE