Agildere, Ahmed M.

Arslan, Serdar

Donmez, Fuldem Y.

Ecevit, Ayse

Neurosciences

English

Baskent Universtiy

296 Neurosciences 2015; Vol. 20 (3)  www.neurosciencesjournal.org
Clinical Note
Value of diffusion-weighted imaging in 
hypoglycemic  encephalopathy
Fuldem Y. Dönmez, MD, Serdar Arslan, MD, 
Ahmed M. Agildere, MD, Ayse Ecevit, MD.
Hypoglycemia is the most common metabolic disorder that may cause neonatal encephalopathy 
and result in permanent brain injury.1 Prompt diagnosis 
is important as urgent treatment may change the 
progression of the disease and the future prognosis. 
Conventional MRI is useful to demonstrate the signal 
changes that are prominent on the occipital lobes; 
however, MRI may not show the pathology in the 
very early period. Diffusion-weighted-imaging (DWI) 
should be obtained prior to other sequences to show 
any early signal changes that are not visible on MRI. 
We report a 3-day-old baby who was admitted to the 
emergency room with the complaint of poor feeding 
and cyanosis. There was no problem perinatally, Apgar 
score was 10 on the first and fifth minutes, and the 
physical examination was normal at birth and when 
discharged from the hospital. At the time of admission, 
he had generalized seizures. The laboratory tests showed 
severe hypoglycemia, blood glucose level was 21 mg/dl 
(normal value 50-80 mg/dl). He was given 2cc/kg 10% 
dextrose, control blood glucose was 78 mg/dl and 
saturation was 95%. Fifteen minutes later, the blood 
glucose decreased again (32 mg/dl) and 100 cc/kg 10% 
dextrose was injected. Despite these injections, control 
glucose levels were 42, 47, and 57 mg/dl, and during 
the acute treatment, seizures repeated. Antiepileptic 
drugs were started (Phenobarbital 20mg/kg infusion 
and 5 mg/kg maintenance dose) and dextrose was 
continued. An MRI of the brain was performed after 
the cessation of the seizures. The conventional MRI was 
normal except for suspicious faint signal increase on the 
left occipital lobe. Fluid-attenuated inversion recovery 
(FLAIR) sequence showed no signal changes (Figure 1A). 
However, diffusion weighted MRI showed significant 
perirolandic and right occipital diffusion restriction, 
which was hyperintense on DWI and hypointense on 
apparent diffusion coefficient map (Figure 1B). The left 
occipital lobe was normal. An MR angiography was 
also normal ruling out any vascular occlusion. During 
follow-up, he did not have any more seizures and serum 
blood glucose was within normal range. Ten days later 
he was discharged with per oral Phenobarbital (2 x 9 
mg) and Diazoxide (3 x 20 mg). An informed consent 
was obtained from his parents.
Neonatal hypoglycemia is associated with 
corticospinal tract injury and adverse motor and 
cognitive outcomes.2 Infants who are small for 
gestational age, the smaller of the twins, babies of toxemic 
mothers, hypocalcemic, and polycythemic patients are 
at risk for hypoglycemia; however, there may not be an 
underlying cause at all times.3 Although it is not easy 
to distinguish hypoxic ischemic encephalopathy and 
hypoglycemic encephalopathy, various injury patterns 
in hypoglycemia are described based on MRI findings. 
Wong et al4 showed that selective posterior white matter 
and pulvinar edema were most predictive of clinical 
hypoglycemia, and no injury or a watershed pattern of 
injury was seen more often in severe hypoglycemia. The 
conventional MRI is good at showing increased signal 
on FLAIR or T2-weighted imaging; however, it may 
not be sensitive in the very early period. The DWI is 
also important as well as conventional techniques. Our 
case did not show any abnormal signal intensity on 
OPEN ACCESS
Figure 1 - Axial fluid-attenuated inversion-recovery image A) does not show any abnormal signal. Apparent coefficient map (ADC) shows B) 
restriction of diffusion on the right insula, posterior parietal, and left parietal lobes.
A B
doi: 10.17712/nsj.2015.3.20140696
297    Neurosciences 2015; Vol. 20 (3) 
DWI in hypoglycemia ... Dönmez et al
www.neurosciencesjournal.org
T2-weighted and FLAIR imaging on the regions that 
showed restriction of diffusion on the DWI. The DWI 
is not only necessary to distinguish vasogenic edema 
versus cytotoxic edema, but also leads to the diagnosis 
itself in case of normal conventional MRI findings. 
In conclusion, in neonates who are suspicious for 
hypoglycemic encephalopathy and have poor sedation, 
priority should be given to DWI before other sequences 
and the protocol should be organized accordingly. 
Received 5th November 2014. Accepted 8th May 2015.
From the Departments of Radiology (Dönmez, Arslan, Agildere), and 
Pediatrics (Ecevit), Faculty of Medicine, Baskent University, Ankara, 
Turkey. Address correspondence and reprint requests to: Dr. Fuldem Y. 
Dönmez, Associate Professor of Radiology, Faculty of Medicine, Baskent 
University, Ankara, Turkey. E-mail: fuldemyildirim@yahoo.com
References
  1. Gataullina S, De Lonlay P, Dellatolas G, Valayannapoulos 
V, Napuri S, Damaj L, et al. Topography of brain damage 
in metabolic hypoglycaemia is determined by age at which 
hypoglycaemia occurred. Dev Med Child Neurol 2013; 55: 
162-166.
  2. Tam EW, Haeusslein LA, Bonifacio SL, Glass HC, Rogers EE, 
Jeremy RJ, et al. Hypoglycemia is associated with increased 
risk for brain injury and adverse neurodevelopmental outcome 
in neonates at risk for encephalopathy. J Pediatr 2012; 161: 
88-93.
  3. Harris DL, Weston PJ, Harding JE. Incidence of neonatal 
hypoglycemia in babies identified as at risk. J Pediatr 2012; 
161: 787-791.
  4. Wong DS, Poskitt KJ, Chau V, Miller SP, Roland E, Hill 
A, et al. Brain injury patterns in hypoglycemia in neonatal 
encephalopathy. AJNR Am J Neuroradiol 2013; 34: 1456-1461.
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Value of diffusion-weighted imaging in hypoglycemic encephalopathy

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Value of diffusion-weighted imaging in hypoglycemic encephalopathy

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