Case Presentation

1. Case Presentation A 48 year old lady presenting with DKA Karuna Spiegelman, M.D. August 9, 2006

2. History of present illness Pat B is a 48 year old Type I diabetic who was transferred from Darlington ER, where she presented with 3 days of nausea, vomiting and intermittent chills. In the ER, she was found to have a blood sugar of 980, pH 6.96, pCO2 11.2, bicarbonate of 2.5. She was placed on an insulin drip and transferred to Meriter Hospital.

3. Review of systems Most of the history is obtained from the patient’s husband as the patient is unable to provide us with any information as she is obtunded. The patient’s blood sugars have recently been in the 400s, despite her taking insulin and other medications as she usually does. She was drinking a lot of water, but did not complain of chest pain, shortness of breath, cough, sputum production, abdominal pain, diarrhea.

4. Past Medical History • Diabetes mellitus Type I for 21 years. • Hypertension, well controlled. • Seizure disorder, no seizures for “many years” on Lamictal • Hysterectomy • Breast lumpectomy, benign • Right lung resection for “lung spots”

5. Allergies • Penicillin Medications • Glargine 10 units BID • Sliding scale insulin with Humalog • Hydrochlorothiazide 25 mg PO daily • Quinine 5 mg PO prn • Lamictal 150 PO BID

6. Social History Pat is married and the mother of 2 grown up children. She works as a registered nurse at a clinic in Darlington, WI. No history of tobacco or alcohol or illicit drug use. Family History Both parents died of cancer of unknown primary. Siblings and children healthy

7. Physical Exam • VITAL SIGNS: BP 98/46, HR 113, Temp 91.3, O2 Sat 99 % on RA. • GEN APP: Obtunded middle-aged female breathing spontaneously, answers yes or no to questions. • HEENT: R pupil reactive 4mm 2 mm. L pupil sluggish and minimally reactive. No oral lesions. Tongue dry and cracked. No carotid bruits, JVD, thyromegaly or LAD. • LUNGS: CTA bilaterally. • HEART: Tachycardia. No gallops, murmurs, rubs, heaves or thrills. • ABDOMEN: Hypoactive bowel sounds. Diffuse, mild to moderate tenderness. • EXTREMITIES: No c/c. No edema. • SKIN: No rashes, echymoses or needle tracks. The skin does tent. • NEUROLOGIC: As described above. She is moving all extremities.

8. Labs • pH 6.96, CO2 11.2, PO2 144, HCO3 2.5, base excess -29 • Na 146, K 4.2, Cl 109, CO2 5, BUN 70, creatinine 2.1, glucose 980 (calculated effective Posm 346) • WBC 24.7, 90% neutrophils, 6% lymphs, 4% monos, HgB 14, Hct 43, plts 525 • Alk phos 189, albumin 4.3, total protein 7.6, Ca 9.8, Mg 3.0, P 6.1, CK 22, Trop 0.06 (Nl) • UA: specific gravity 1.025, ketones>80, protein 30, WBC 0-1, bacteria 1+.

9. Imaging • EKG: normal axis, sinus tachycardia, minimal ST depression. • CXR: no infiltrates, cardiomegaly, pulmonary edema or pleural effusions.

10. So, what is so interesting in a patient with DKA?????

11. Day # 3 • Pat has received 10 L of fluid. • Anion gap has closed, electrolytes are normalizing. • She is still obtunded and minimally responsive.

12. Additional imaging • Head CT: No acute process. • Brain MRI: Multifocal ischemia in the left hemisphere: one in superior frontal white matter, one in the superior parietal lobe, one in deep parietal subependymal region. No hemorrhage.

13. Additional imaging • MRI of the neck: Left internal carotid artery has a small caliber as compared to the right. This is a smoothly marginated process extending the entire length of the left ICA. The left ICA is patent throughout the entire course. • MRA of the brain: Diminutive presentation of the left ICA. Dissection is not identified. Distal left ICA is has some suggestion of vessel wall thickening, but no occlusion is seen along the left ICA. Right ICA has relatively normal course and caliber.

14. Carotid artery stenosis

15. Carotid artery stenosis • Dissection • Atherosclerosis • Vasculitis • Fibromuscular dysplasia • Congenital

16. Carotid artery sclerosis • Prevalence in US: Estimates indicate that 5 per 1000 persons aged 50-60 years and approximately 10% of persons older than 80 years have carotid stenosis greater than 50%. • Sex: Almost equal frequency in men and women. In general, women are more likely to seek and receive treatment for both benign and symptomatic carotid stenosis. • Age: Extracranial carotid disease more frequently in elderly persons. In patients with increased risk factors, the age at first presentation tends to be younger

17. Symptoms • Amaurosis fugax ( Temporary loss of vision in one eye) • Transient ischemic attacks (TIA) • Reversible ischemic neurological deficits (RIND) • Cerebral vascular attack • 75 % of people who suffer a stroke related to carotid artery disease have a warning in the form of a transient ischemic attack (TIA) prior to the stroke • In patients older than 60 years who have cerebral infarction, approximately 15% have ipsilateral carotid stenosis of 70% or greater. In 40-50% of those with a complete stroke, the primary etiology of the stroke is related to extracranial carotid disease (stenosis). • Increased risk for MI

18. Risks • Atherosclerosis • Hypertension • Smoking • Hyperlipidemia • Obesity • Diabetes • Lack of regular exercise • Uncontrolled stress and anger

19. Imaging • Duplex carotid sonography • CT angiography (CTA) • Magnetic resonance angiography (MRA) of the carotid artery • Carotid angiography • Oculoplethysmography. Measures the arterial blood pressure in each eye and compares the readings to the blood pressure readings in each arm. Hardly used today.

20. When to treat • Symptomatic with 70 % stenosis. Carotid artery repair reduces the 2 year risk of stroke from 26% to 9% • Symptomatic with stenosis of 50-70% - still benefit from repair. • Asymptomatic if stenosis of 60% or greater (20) • Stenosis of less than 50 % has no proven benefit • About 4 % of adults have asymptomatic neck bruits • Benefits of carotid endarterectomy are slightly better in men than in women perhaps because women have smaller arteries.

21. When to treat • North American Symptomatic Carotid Endarterectomy Trial (NASCET) Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53. • European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991;337:1235-43. • Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289-94.

22. Treatment • Endovascular stenting and angioplasty • Catheter-directed thrombolytic therapy (thrombosis) • Carotid endarterectomy

23. Follow-up So, what happened to Pat…… Day # 3 (after we obtained the MRI) she woke up Rheumatology - vasculitis? Neurology - rapid and remarkable recovery Neurosurgery - stenting v/s bypass She continues to follow with her neurologist locally …..

24. Discussion • DKA and CVA • Not often in the literature • More common in children • Low threshold for head CT • Mostly cerebral edema • Second case • Is it more often than we think?

25. References • North American Symptomatic Carotid Endarterectomy Trial (NASCET) Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53. • European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991;337:1235-43. • Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289-94. • (24) Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998;339:1415-25.

26. References cont’d • CASANOVA Study Group. Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke 1991;22:1229-35. Mayo Asymptomatic Carotid Endarterectomy Study Group. Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Clin Proc 1992;67:513-8. • Hobson RW 2d, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med 1993;328:276-9. • Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-8.

27. References cont’d • http://www.emedicine.com/EMERG/topic135.htm • http://www.emedicine.com/radio/topic133.htm • http://www.mayoclinic.org/carotid-artery-disease/index.html • http://www.mayoclinic.org/carotid-artery-disease/treatment.html • http://www.aafp.org/afp/20000115/400.html