The Journal of Pediatrics
Volume 153, Issue 4 , Pages 541-546.e1, October 2008

Correlation of Clinical and Biochemical Findings with Diabetic Ketoacidosis–Related Cerebral Edema in Children Using Magnetic Resonance Diffusion-Weighted Imaging

  • Nicole S. Glaser, MD

      Affiliations

    • Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
    • Corresponding Author InformationReprint requests: Nicole Glaser, MD, Department of Pediatrics, University of California Davis, School of Medicine, 2516 Stockton Blvd, Sacramento, CA 95817
    • ,
  • James P. Marcin, MD, MPH

      Affiliations

    • Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
    • ,
  • Sandra L. Wootton-Gorges, MD

      Affiliations

    • Department of Radiology, University of California, Davis School of Medicine, Sacramento, CA
    • ,
  • Michael H. Buonocore, MD, PhD

      Affiliations

    • Department of Radiology, University of California, Davis School of Medicine, Sacramento, CA
    • ,
  • Arleta Rewers, MD, PhD

      Affiliations

    • Department of Pediatrics, University of Colorado, School of Medicine, Denver, CO
    • ,
  • John Strain, MD

      Affiliations

    • Department of Radiology, University of Colorado, School of Medicine, Denver, CO
    • ,
  • Joseph DiCarlo, MD

      Affiliations

    • Department of Pediatrics, Stanford University School of Medicine, Sacramento, CA
    • ,
  • E. Kirk Neely, MD

      Affiliations

    • Department of Pediatrics, Stanford University School of Medicine, Sacramento, CA
    • ,
  • Patrick Barnes, MD

      Affiliations

    • Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
    • Department of Radiology, Stanford University School of Medicine, Sacramento, CA
    • ,
  • Nathan Kuppermann, MD, MPH

      Affiliations

    • Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
    • Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA

Received 6 December 2007; received in revised form 18 March 2008; accepted 14 April 2008. published online 01 July 2008.

Objective

To determine clinical and biochemical factors influencing cerebral edema formation during diabetic ketoacidosis (DKA) in children.

Study design

We used magnetic resonance diffusion-weighted imaging to quantify edema formation. We measured the apparent diffusion coefficient (ADC) of brain water during and after DKA treatment in 26 children and correlated ADC changes with clinical and biochemical variables.

Results

Mean ADC values were elevated during DKA treatment compared with baseline (8.13 ± 0.47 vs 7.74 ± 0.49 × 10−4 mm2/sec, difference in means 0.40, 95% CI: 0.25 to 0.55, P < .001). Children with altered mental status during DKA had greater elevation in ADC. ADC elevation during DKA was positively correlated with initial serum urea nitrogen concentration (correlation coefficient 0.41, P = .03) and initial respiratory rate (correlation coefficient 0.61, P < .001). ADC elevation was not significantly correlated with initial serum glucose, sodium or effective osmolality, nor with changes in glucose, sodium or osmolality during treatment. Multivariable analyses identified the initial urea nitrogen concentration and respiratory rate as independently associated with ADC elevation.

Conclusions

The degree of edema formation during DKA in children is correlated with the degree of dehydration and hyperventilation at presentation, but not with factors related to initial osmolality or osmotic changes during treatment. These data support the hypothesis that CE is related to cerebral hypoperfusion during DKA, and that osmotic fluctuations during DKA treatment do not play a primary causal role.

Abbreviations: ADC, Apparent diffusion coefficient, CE, Cerebral edema, DKA, Diabetic ketoacidosis, DWI, Diffusion-weighted imaging, GCS, Glasgow Coma Scale, MRI, Magnetic resonance imaging

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 Supported by research awards from the American Diabetes Association and the University of California, Davis Health System. The study sponsors played no role in the design or conduct of the study, data collection, analysis or interpretation, nor in the preparation, review, or approval of the manuscript.

 The authors declared no potential conflict of interest.

PII: S0022-3476(08)00315-6

doi:10.1016/j.jpeds.2008.04.048

The Journal of Pediatrics
Volume 153, Issue 4 , Pages 541-546.e1, October 2008

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