Uncommon extensive juxtacortical necrosis of the brain

Summary

A previously healthy woman in middle age, vacationing in Spain, is treated with a massive dose of insulin for minimal hyperglycemia following an apparent gastrointestinal disease. This results in rapid coma and, 20 days later, in death. At autopsy, the main finding consists in a remarkable and uncommon ribbon-like juxtacortical necrosis of the white matter in both hemispheres of the telencephalon. There is also a microscopic focal necrosis in the pons cerebri. The grey matter of cortex and basal nuclei, and the subcortical arcuate fibers are spared. The detailed autopsy fails to reveal other essential changes. We have not been able to find reports on an identical case. Hypoglycemic coma usually causes cerebral lesions different from those seen in the present case. A brief analysis of the differential diagnosis is made. In the absence of unequivocal signs of infection, vascular disease or degenerative marks, the findings are tentatively related to complex interactions between fluid loss, hypoglycemic coma, hypoxia and other metabolic disturbances.