Sequential presentation of diabetic ketoacidosis, acute ischemic stroke, and ST-elevation in myocardial infarction: a case report

Abstract

Cardio-cerebral infarction is the simultaneous occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), and it is a rare and life-threatening emergency. Management thereof is more challenging when it is accompanied by metabolic complications such as diabetic ketoacidosis (DKA). Here, we report a case of a 45- year-old man with hypertension and a history of chronic smoking, who was found unresponsive with right-sided hemiparesis. He was well when last seen 6 hours before arrival. Upon examination, he was hypertensive, tachypneic, had a ketotic breath odor, a Glasgow Coma Scale of 12, and a National Institutes of Health Stroke Scale score of 15. Laboratory results confirmed DKA, with a random blood glucose of 412 mg/dL and metabolic acidosis, and a noncontrast brain computed tomography revealed an acute infarct in the left parietal lobe. Initial management included intravenous fluids, insulin, and clopidogrel. Six hours after admission, he developed sudden chest pain radiating to the jaw with diaphoresis; an electrocardiogram revealed inferior–posterior ST-segment elevation. He was treated with intravenous morphine and dual antiplatelet therapy. Echocardiography on day 2 revealed akinetic left ventricular anterior segments and a reduced ejection fraction (39.0%). This case emphasizes the need for the rapid, multidisciplinary management of concurrent DKA, AIS, and ST-elevation myocardial infarction. Careful timing of the interventions to balance bleeding, thrombolysis, and hemodynamic risks, combined with the coordinated input from neurologists, cardiologists, and endocrinologists, enabled patient stabilization and discharge on day 6 with improved neurological and cardiac outcomes.