Change in blood-brain barrier permeability during pediatric diabetic ketoacidosis treatment

Objective: Cerebral edema is a devastating complication of pediatric diabetic ketoacidosis. We aimed to examine blood-brain barrier permeability during treatment of diabetic ketoacidosis in children. Design: Prospective observational study. Setting: Seattle Children's Hospital, Seattle, WA. Patients: Children admitted with diabetic ketoacidosis (pH < 7.3, HCO3 <15 mEq/L, glucose >300 mg/dL, and ketosis). Interventions: None. Measurements and Main Results: Subjects underwent two serial paired contrast-enhanced perfusion (gadolinium) and diffusion magnetic resonance imaging scans. Change in whole brain and regional blood-brain barrier permeability (permeability ratio*100 and % permeability ratio change) between illness and recovery were determined. Time 0 reflects start of insulin treatment. Thirteen children (median age 10.0 +/- 1.1 yrs; seven female) with diabetic ketoacidosis were enrolled. Permeability ratio increased from time 1 (first magnetic resonance image after time 0) to time 2 (second magnetic resonance image after time 0) in the frontal cortex (ten of 13 subjects), occipital cortex (ten of 13 subjects), and basal ganglia (nine of 13). Whole brain permeability ratio increased from time 1 to time 2 (160%) and regional increase in permeability ratio was greatest in the frontal cortex (148%) compared with the occipital cortex (128%) and basal ganglia (112%). Conclusions: Overall, whole brain and regional blood-brain barrier permeability increased in most subjects during diabetic ketoacidosis treatment. The frontal region had more blood-brain barrier permeability than other brain regions examined. (Pediatr Crit Care Med 2010; 11: 332-338)