Subarachnoid Hemorrhage as a Complication of Diabetic Ketoacidosis in Early Onset Type 1 Diabetes Melitus in Limited Resource Settings

Abstract

Background: Diabetic ketoacidosis (DKA) is one of the most frequent causes of morbidity and mortality in type 1 diabetes mellitus (T1DM). Neurological complications that can occur in DKA patients are cerebral edema followed by ischemic and hemorrhagic strokes. Hemorrhagic strokes have higher mortality than ischemic strokes in T1DM patients. Case: An 11-year-old patient came to the emergency room with complaints of decreased consciousness since morning. During the previous 2 days the patient had nausea and vomiting. There was no history of trauma or fever. About 2 days before admission patient showed decrease of consciousness. On physical examination, he was found to be in a coma, kussmaul breathing, mydriatic pupil, and with kussmaul breathing. Laboratory examination showed hyperglycemia, leukocytosis, hyponatremia, ketonuria, and C-peptide of 0,560 ng/ml. Head CT-Scan showed subarachnoid hemorrhage and cerebral edema. The patient showed a positive response after rehydration, administration of mannitol, and blood sugar regulation with an insulin pump. Discussion: DKA is one of the manifestations of T1DM. DKA is confirmed by hyperglycemia, blood pH below 7.3 manifesting with kussmaul breathing and the presence of ketones in blood and urine tests. DKA is treated with rehydration and insulin administration. SAH is a rare manifestation of DKA. The diagnosis of SAH can be confirmed by neuroimaging examination. Management of SAH could be done through close monitoring of blood pressure, prevention of increased intracranial pressure, and surgical approach. Conclusion: Subarachnoid hemorrhage is a neurological complication that rarely happens in DKA and could be caused by several factors such as hypotensive episode, hyperketonemic state, arteriovenosus malformation rupture, and endothelial perturbation. Neuroimaging could detect early neurological complication in DKA.