Diabetic ketoacidosis and cerebral edema: a rare case of infarct-like MRI findings in a pediatric patient

Introduction and importance: Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening complication of type ۱ diabetes mellitus, particularly in pediatric patients. Cerebral edema (CE) is a rare but devastating consequence of DKA. Although neuroimaging findings in CE are typically nonspecific, infarct-like changes are exceedingly rare and may complicate clinical management. Case presentation: We report the case of an ۱۱-year-old boy with a history of type ۱ diabetes mellitus who presented with epigastric pain, vomiting, polydipsia, and polyuria. Despite timely initiation of standard treatment for DKA, the patient developed acute neurological deterioration consistent with CE. Brain MRI revealed restricted diffusion in the basal ganglia, corpus callosum, and internal capsule - findings suggestive of infarction rather than typical vasogenic edema. Clinical discussion: This case highlights the diagnostic and therapeutic challenges posed by DKA-associated CE with atypical imaging findings. The observed infarct-like MRI pattern is rarely reported and may reflect underlying cytotoxic edema or ischemic injury. Understanding the multifactorial pathophysiology - including osmotic shifts, inflammatory processes, and impaired cerebral autoregulation - is critical for effective management. Conclusion: Early recognition of atypical cerebral involvement in pediatric DKA is essential. Advanced neuroimaging can aid in diagnosis and guide appropriate intervention. Clinicians should remain vigilant for neurological complications even during early phases of treatment and consider infarct-like patterns in differential diagnosis.