Özlem KENDİR, Hayri YILMAZ, Nilgun ERKEK, Sinem SARI GÖKAY, Dinçer YILDIZDAŞ, Bilgin YÜKSEL

DİYABETİK KETOASİDOZLU OLGULARDA OPTİK SİNİR KILIF ÇAPI ÖLÇÜMÜ İLE BEYİN ÖDEMİ ÖNGÖRÜLEBİLİR Mİ?: BİR ÖNCÜL ÇALIŞMA

Amaç: Diyabetik ketoasidozda (DKA) beyin ödeminin klinik belirti ve semptomları her zaman açık olmayabilir. İntrakraniyal basınç arttığında, optik sinir kılıfı çapı (OSKÇ) aynı anda artar ve ultrasonografi ile görüntülenebilir. Bu çalışmada, DKA’da beyin ödemi (BÖ) varlığında OSKÇ değerlerinin belirleyici özelliklerinin tartışılması amaçlandı. Gereç ve Yöntem: Çalışmaya hafif, orta ve şiddetli DKA tanılı hastalar dahil edildi. Tedavinin ilk iki saatinde hastanın gözleri kapalı, sırtüstü nötral pozisyonda yatarken transorbital ultrasonografi uygulandı. Globun 3 mm derinliğinde hipoekoik çift kenarlı bir çizgi olarak görünen optik sinir kılıf çapları ölçüldü. Poliklinik kontrollerinde de aynı ölçümler tekrarlandı. Hastaların OSKÇ değerleri ile metabolik ve nörolojik durumları karşılaştırıldı. Bulgular: Yaş ortalaması 8,8±3 (SS) yıl olan sekiz hasta çalışmaya dahil edildi. Bunlardan yedisinde orta-şiddetli DKA vardı. Bilgisayarlı beyin tomografisinde (BT) baş ağrısı olan iki hastanın hafif BÖ olduğu görüldü. Orta-şiddetli DKA’lı hastalarda OSKÇ 5,7±0,93 mm (ortalama±SD (Standard Sapma)), hafif DKA’lı tek hastada ise 4 mm idi. BT’de BÖ’lü 2 hastanın OSKÇ’si 6,8 mm ve 5,9 mm idi. Şiddetli DKA’lı beş hastanın tedaviden bir hafta sonraki poliklinik kontrolünde ortalama OSKÇ 4,4±0,32 mm idi. Sonuç: USG ile OSKÇ ölçümü, DKA’lı çocuklarda BÖ’yü tahmin etmek için destekleyici bir yöntem olabilir.

Anahtar Kelimeler:

Diyabetik ketoasidoz, optik sinir kılıf çapı ölçümü, beyin ödemi

CAN BRAIN EDEMA BE PREDICTED WITH OPTIC NERVE SHEATH DIAMETER MEASUREMENT IN CASES WITH DIABETIC KETOACIDOSIS?: A PRELIMINARY STUDY

Objective: The clinical signs and symptoms of brain edema resulting from diabetic ketoacidosis (DKA) may not always be ob vious. When the intracranial pressure increases, the optic nerve sheath diameter (ONSD) simultaneously increases and can be imaged with ultrasonography. We aimed to discuss the determinative features of ONSD measurements in brain edema (BE) in DKA. Materials and Methods: Patients who were classified as having mild, moderate and severe DKA were included in the study. Transorbital ultrasonography was performed during the first two hours of treatment while the patients remained in the supine neutral position with their eyes closed. The optic nerve sheath diameters, which appeared as a hypoechoic double-edged line 3 mm deep to the globe, were measured. The same measurements were repeated in outpatient clinic controls. The ONSD values and metabolic, neurological conditions of the patients were compared. Results: Eight patients with a mean age of 8.8±3 (Standard Deviation (SD)) years were included in the study. Seven of them presented with moderate to severe DKA. Two patients suffering from headaches were found to have mild BE according to the brain computerized tomography (CT). The ONSD was 5.7±0.93 mm (mean±SD) in the patients with moderate-severe DKA and 4 mm in the single patient with mild DKA. The ONSDs of the two patients with BE on the CT were 6.8 mm and 5.9 mm. The mean ONSD of the five patients with severe DKA was 4.4±0.32 mm in the outpatient clinic checks. Conclusion: The measurement of ONSD by USG may be a supportive method for predicting BE in children with DKA.

Keywords:

Diabetic ketoacidosis, Optic nerve sheath diameter measurement, Brain edema.,

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1. Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC. Definition, epidemiology and classification of diabetes in children and adolescents. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium Chapter 1. Pediatric Diabetes 2014;15(20);4-17. [CrossRef]
2. Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014;15(20):154-79. [CrossRef]
3. Maniatis AK, Goehrig SH, Gao D, Rewers A, Walravens P, Klingensmith GJ. Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed Type 1 Diabetes Mellitus. Pediatric Diabetes 2005;6(2):79-83. [CrossRef]
4. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004;27(7):1541-6. [CrossRef]
5. Botero D, Wolfsdorf JI. Diabetes mellitus in children and adolescents. Archives of Medical Research 2005;36(3): 281- 90. [CrossRef]
6. Saldatos T, Karakitsos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Critical Care 2008;12(3):R67. [CrossRef]
7. Qayyum H, Ramlakhan S. Can oculer ultrasound predict intracranial hypertension? A pilot diagnostic accuracy evaluation in a UK emergency department. Eur J Emerg Med 2013;20(2):91-7. [CrossRef]
8. Steinborn M, Friedman M, Hahn H, Hapfelmeler A, Macdonald E, Warncke K, et al. Normal values for transbulbar sonography and magnetic resonance imaging of the Optic Nerve Sheath Diameter (ONSD) in children and adolescents. Ultraschall in med 2015;36:54-8. [CrossRef]
9. Wang L, Feng l, Yao Y, Wang Y, Chen Y, Feng J, et al. Optimal optic nerve sheath diameter threshold for the identification of elevated opening pressure on lumbar puncture in a chinese population. Plos ONE 2015;10(2):e0117939. [CrossRef]
10. Saldatos T, Chatzimichail K, Papathanasiou M, Gouliamos A. Optic nevre sonography: a new window for the noninvasive evaluation of intracranial pressure in brain injury. Emerg Med J 2009;26(9):630-634. [CrossRef]
11. Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TP, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004;113(2):e133-140. [CrossRef]
12. Szmygel L, Kosiak W, Zorena K, Mysliwiec M. Optic nerve and cerebral edema in the course of diabetic ketoacidosis. Curr Neuropharmacol 2016;14(8):784-91. [CrossRef]
13. Karakitsos D, Saldatos T, Goulimos A, Armaganidis A, Poularas J, Kalogeromitros A, et al. Transorbital sonographic monitoring of optic nerve diameter in patients with severe brain injury. Transplant Proc 2006;38(10):3700-6. [CrossRef]
14. Nawal NS, Mohamed A, Alharbi A, Ansari H, Zaza KJ, Marashly Q, et al. The incidence of increased ICP in ICU patients with non-traumatic coma as diagnosed by ONSD and CT: a prospective cohort study. BMC Anesthesiol 2016;16(1):106 (8p). [CrossRef]
15. Bergmann KR, Milner DM, Voulgaropoulos C, Cutler GJ, Kharbanda AB. Optic nerve sheath diameter measurement during diabetic ketoacidosis: A pilot study. West J Emerg Med 2016;17(5):531-41. [CrossRef]
16. Hansen G, Sellers EA, Beer DL, Vallance JK, Clark I. Optic nerve sheath diameter ultrasonography in pediatric patients with diabetic ketoacidosis. Can J Diabetes 2016;40(2):126- 30. [CrossRef]
17. Kendir OT, Yılmaz HL, Ozkaya AK, Gökay SS, Bilen S, Yıldızdaş RD, et al. Determination of cerebral edema with serial measurement of optic nerve sheath diameter during treatment in children with diabetic ketoacidosis: a longitudinal study. J Pediatr Endocrinol Metab 2019;32(9):943-49. [CrossRef]