A 49-year-old man with a history of type 1 diabetes self-presented to hospital, with ataxia and memory impairment. Admission blood glucose was 1.9 mmol/L. Using a combination of intravenous and orally administered glucose, the patient became euglycaemic 45 min later. Marked cognitive impairment was noted to persist several days into his admission. An MRI of the brain scan was performed, demonstrating numerous foci of restricted diffusion involving the anterior and posterior territories (figures 1 and 2), including the cortex, subcortical white matter, deep white matter and corpus callosum. Blood tests for autoimmune, inflammatory and thrombogenic conditions, telemetry, echocardiography and angiographic studies of the extra and intracranial vessels, failed to demonstrate evidence of a thrombotic cause. The presence of multiple territory changes involving deep and cortical regions in the absence of vascular pathology made hypoglycaemic encephalopathy the only explanation for the presentation and findings.
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