Abstract
BackgroundAbnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention.MethodsWe identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging.ResultsBetween two institutions, we identified six patients—ages 33–59 years, four male—with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up.ConclusionsWe present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.
Highlights
Cytotoxic edema, identified by restricted diffusion on magnetic resonance imaging (MRI), can be associated with acute ischemic stroke, hypoxic-ischemic encephalopathy (HIE) [1], posterior reversible encephalopathy syndrome (PRES) [2], and various toxidromes [3] including the use of inhaled opiates (i.e., “chasing the dragon”) [4]
We identified an ad hoc series of patients seen at the University of Cincinnati Medical Center and University of Tennessee Methodist University Hospital between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging
Demographics and Clinical Presentation We identified four patients at the University of Cincinnati Medical Center and two at University of Tennessee Methodist University Hospital with similar imaging findings of severe, bilateral, otherwise unexplained cerebellar cortical edema, identified by restricted diffusion on MRI
Summary
Cytotoxic edema, identified by restricted diffusion on magnetic resonance imaging (MRI), can be associated with acute ischemic stroke, hypoxic-ischemic encephalopathy (HIE) [1], posterior reversible encephalopathy syndrome (PRES) [2], and various toxidromes [3] including the use of inhaled opiates (i.e., “chasing the dragon”) [4]. We describe a unique series of cases with a clinicoradiographic syndrome of stupor or coma with imaging findings of bilaterally symmetric abnormally restricted diffusion in the cerebellar cortex, hippocampi, and variable aspects of the basal nuclei. This pattern of acute injury is distinct from previously described conditions and may represent an under-recognized clinical syndrome we term Cerebellar Hippocampal And basal Nuclei Transient Edema with Restricted diffusion (CHANTER) Syndrome. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention
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