Bilateral Posterior Circulation Stroke in a Child with Type 1 Diabetes Mellitus

A 10-year old girl presented with acute onset fever, headache, recurrent seizures, and encephalopathy for 2 days. She was diagnosed to have type-1 diabetes mellitus at 8 years of age and managed with subcutaneous insulin therapy. She had a history of recurrent episodes of hypoglycemia and hyperglycemia due to poor compliance. On examination, she was encephalopathic (Glasgow coma scale score of 11), hypertensive (blood pressure [BP]: 132/80 mm Hg), had normal fundus and anthropometric parameters. Her pupils were dilated with preserved reaction and she had right sided hemiparesis and left sided ptosis. Initial investigations showed severe acidosis (pH 7.15), ketosis, and hyperglycemia (26.8 mmol/L). A diagnosis of severe diabetic ketoacidosis with raised intra cranial pressure (ICP) was considered. Her glycosylated hemoglobin was 9.8% reflecting poor glycemic control. She was managed with isotonic fluid, insulin therapy, multiple antiepileptic drugs, mechanical ventilation, and antiraised ICP measures for cerebral edema. Following recovery from encephalopathy, she was noticed to have bilateral cortical vision impairment. Magnetic resonance imaging (MRI) of the brain showed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities in posterior cerebral artery territory involving occipital and posterior temporal lobes. Anteroposterior stretching of midbrain with bilateral uncal herniation causing compression of pons was notable on the MRI brain ([Fig. 1]). Magnetic Resonance angiography showed attenuation of bilateral posterior cerebral arteries ([Fig. 2]). After 1 month of follow-up, visual acuity improved to perception of light.

Fig.1 MRI T2-weighted (A, B), T1-weighted (C) and fluid-attenuated inversion recovery sequence (D) showing hyperintensities in bilateral occipital (A) and bilateral temporal lobes (left > right) (B, D). The midbrain is anteroposteriorly flattened (black arrow) (B, C) and shows uncal protrusion in suprasellar cisterns (white arrow) (D).MRI, magnetic resonance imaging.

Fig. 2 MRI angiography showing attenuation of bilateral distal posterior cerebral arteries. MRI, magnetic resonance imaging.

The index case highlights the need of emergency interpretation of neuroradiology in patients with raised ICP. Occipital lobe involvement is commonly seen with severe neonatal hypoglycaemia, posterior reversible encephalopathy syndrome, inflammatory granuloma, and neoplastic disorders. Rarely, bilateral occipital lobe involvement can occur due to ischemic infarcts in the bilateral posterior cerebral artery territories.[1] [2] Evidence of uncal herniation was clearly evident on MRI brain in the form of bulge into the suprasellar cistern. The downward push of both the uncus caused compression of posterior cerebral artery between the temporal lobe and crus cerebri leading to ischemic infarcts.[1] [2] This child highlights the fact that bilateral posterior cerebral arterial (PCA) territory infarcts can be a serious complication of diabetic ketoacidosis secondary to uncal herniation as a result of cerebral edema. The knowledge of this fact and clinic-radiological interpretation can help in aggressive management of raised ICP due to cerebral edema which can be life-saving and timely restoration of perfusion can help in preservation of vision.

Authors' Contributions

S.R.D.: Preparation of the draft of manuscript and review of the literature.

R.S.: Critical review of manuscript for important intellectual content and final approval of the version to be published.

H.P.: Contribution to the draft of the manuscript, critical review of manuscript for important intellectual content, and approval of the version to be published.

Prof. P.S.: Analysis of the radiologic data, critical review of manuscript, and final approval of the version to be published.

D.: Edited the manuscript, clinical care, contributed to intellectual content, and final approval of the version to be published.

N.S.: Edited the manuscript, clinical care, contributed to intellectual content, and final approval of the version to be published.

Ethical Approval

An informed consent form was signed by the parents of the patient to approve the use of patient information or material for scientific purposes.

• References

• 1 Sato M, Tanaka S, Kohama A, Fujii C. Occipital lobe infarction caused by tentorial herniation. Neurosurgery 1986; 18 (03) 300-305
• 2 Mohseni M, Habibi Z, Nejat F. Contralateral superior cerebellar artery syndrome: a consequence of brain herniation. J Korean Neurosurg Soc 2017; 60 (03) 362-366