Objective:

To describe a rare and unusual presentation of focal status epilepticus (FSE) mimicking acute stroke in a patient with diabetic ketoacidosis (DKA).

Background:

Seizures are an uncommon manifestation of hyperglycemic crises, typically presenting as generalized seizures, especially among pediatric patients. Focal seizures without identifiable structural brain lesions are extremely rare in patients with DKA and can cause diagnostic confusion when presenting with lateralizing neurological deficits.

Design/Methods:

We report the case of a 53-year-old man with type 1 diabetes mellitus who developed acute-onset left hemiparesis, dysarthria, and rightward gaze deviation (NIHSS score of 16). On presentation, he had severe hyperglycemia (450 mg/dL), metabolic acidosis, and elevated ketones. Comprehensive neuroimaging—including CT, CTA, CT perfusion, and MRI—revealed no evidence of stroke. Long-term video EEG monitoring was performed due to persistent focal neurological deficits.

Results:

Continuous EEG monitoring demonstrated frequent electrographic seizures arising from the right parietal–occipital region with paroxysmal fast activity evolving into rhythmic spiking, consistent with focal status epilepticus. Seizures persisted despite levetiracetam and lacosamide treatment, meeting criteria for new-onset refractory status epilepticus (NORSE). Intubation, continuous anesthetic infusions, and ultimately triple antiseizure therapy (including clobazam) were required for seizure control by day 4. DKA was managed with IV insulin, fluid resuscitation, and electrolyte replacement, with normalization of the anion gap by hospital day 2. Cerebrospinal fluid (CSF) analysis did not support an infectious or autoimmune etiology.

Conclusions:

FSE can serve as a primary neurological manifestation of DKA and may closely mimic acute stroke. In cases of focal deficits without corresponding imaging abnormalities in diabetic patients, early EEG evaluation is crucial for accurate diagnosis. Recognizing this unusual presentation can prevent diagnostic delays and guide appropriate management—combining aggressive seizure control with metabolic correction.