Sequential Presentation of Diabetic Ketoacidosis, Acute Ischemic Stroke, and ST-Elevation Myocardial Infarction: A Case Report

Cardio-cerebral infarction (CCI), the simultaneous occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), is a rare and life-threatening emergency. Management becomes even more challenging when accompanied by metabolic complications like diabetic ketoacidosis (DKA). We report a case of a 45-year-old man with hypertension and a chronic smoking history, found unresponsive with right-sided hemiparesis. He was last seen well six hours before arrival. On examination, he was hypertensive, tachypneic, had a ketotic breath odor, GCS 12, and NIHSS 15. Laboratory results confirmed DKA, with a random blood glucose of 412 mg/dL and metabolic acidosis. Non-contrast brain CT revealed an acute infarct in the left parietal lobe. Initial management included IV fluids, insulin, and clopidogrel. Six hours after admission, he developed sudden chest pain radiating to the jaw with diaphoresis; ECG showed inferior–posterior ST-segment elevation. He was treated with intravenous morphine and dual antiplatelet therapy. Echocardiography on day two revealed akinetic left ventricular anterior segments, and a reduced ejection fraction (39%). This case underscores the need for rapid, multidisciplinary management of concurrent DKA, AIS, and ST-elevation myocardial infarction (STEMI). Careful timing of interventions to balance bleeding, thrombolysis, and hemodynamic risks, combined with coordinated input from neurologists, cardiologists, and endocrinologists, enabled patient stabilization and discharge on day six with improved neurological and cardiac outcomes.