Presentation
Brought to the casualty department comatosed.
Patient Data
Bilateral cerebral cortical and subcortical patchy and confluent lesions with restricted diffusion are seen with hyperintense DWI, low ADC signal and subtle T2/FLAIR hyperintensity. The amygdalae, the hippocampi as well as the insular cortices are seen involved. The deep grey matter nuclei (basal ganglia) as well as the the thalami and the cerebellum are spared.
A few bilateral cerebral deep white matter lesions with hyperintense T2/FLAIR signal are seen consistent with chronic small vessel disease.
Case Discussion
The cause was suicide attempt by overdosage of insulin in a patient who has psychiatric disorders and is unknown to be diabetic.
Hypoglycemic brain injury is typically diagnosed in comatose adult diabetic men on insulin with brain insult due to insulin overdosage. The lesion usually involves the frontal, parietal, temporal and occipital cortex and subcortex with relative sparing of the deep white matter. The basal ganglia are involved in severe cases. The thalami are always spared as well as the cerebellum and the brain stem.
The lack of deep white matter injury, hemorrhagic reperfusion as well as the lack of the thalamic affection are the main differentiating points between hypoglycemic and hypoxic-ischemic brain insult.
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