Diagnosis Of Central Pontine Myelinolysis Research Articles

A Case of Central Pontine Myelinolysis due to Severe Acute Prolonged Hyponatremia in Our County Hospital

Background: Central pontine myelinolysis (CPM)is unique and rare clinical entity. It could be a neurological complication of prolonged hyponatraemia. Many predisposing risk factors (chronic alcoholism, malnutrition, malignancy) may aggravate the development of CPM. CPM usually have a poor or even fatal outcome. However, CPM does not inevitably have a bad prognosis, and could occur with proper restoration of normal serum sodium concentrations. Case Summary: Here, we presented a case of a 48-year-oldfemale. She used to drink alcohol. She presented to Our Lady’s Hospital/Navan with a history of four days feeling unwell, confused diarrhea, vomiting and by investigations, she had severe hyponatraemia. She was managed optimally in the ICU with close monitoring of her urea and electrolytes. Unfortunately, she got progressive neurological deficits (lower limbs weakness, and slurred speech) irrespective of gentle treatment of hyponatremia in intensive care unit. After Neurological and radiological input from Dublin institute, CPM confirmed under background of alcoholism and malnutrition. Following the diagnosis of CPM, she was discharged home after been rehabilitated with physiotherapy with ongoing recovery.

Ayurvedic understanding of Central Pontine Myelinolysis - A Case Report

A 56 year old male patient was admitted to S.D.M Ayurveda Hospital, Hassan, Karnataka with the confirmed diagnosis of Central Pontine Myelinolysis (CPM) on 11/12/17. The chief complaints were weakness of both hands and legs, stiffness in both hands and legs, pain in both shoulder joints, slurred speech, difficulty in walking with gait changes. H/O chronic alcoholism. MRI brain showed pontine and basal ganglia diffusion restriction - Acute Pontine Myelinolysis. The serum electrolyte showed serum sodium level as 128 mmol/litre. This disease can be understood as Samana Avruta Vyana in hyponatremic encephalopathy stage and the stage of myelinolysis can be understood as Sarvanga Vata with Kapha Avruta Udana and Vyana. After clinical evaluation, Avarana Chikitsa was started followed by Kevala Vatika Chikitsa and significant improvement was seen. Significant result was observed in subjective and objective parameters after the treatment. The patient was discharged with oral medications for 1 month.

Poster 282 Functional Gains after Diagnosis of Central Pontine Myelinolysis due to Hypophosphatemia in a Leukemia Patient on an Acute Inpatient Rehabilitation Unit: A Case Report

Poster 282 Functional Gains after Diagnosis of Central Pontine Myelinolysis due to Hypophosphatemia in a Leukemia Patient on an Acute Inpatient Rehabilitation Unit: A Case Report

Recovery of locked-in syndrome following liver transplantation with calcineurin inhibitor cessation and supportive treatment

SummaryBackground:Locked-in syndrome represents the most severe form of central pontine myelinolysis (CPM) and has been associated with a dismal outcome.Case Report:In this report we describe a case of severe locked-in syndrome after liver transplantation with spontaneous recovery with cessation of calcneurin inhibitor therapy and supportive treatment.A 54-year old male received deceased-donor liver transplantation and developed decreased level of consciousness with spastic quadriplegia. A diagnosis of central pontine myelinolysis with extrapontine manifestations was confirmed by magnetic resonance imaging. His immunosuppresion was modified by switching from tacrolimus to sirolimus and addition of prednisone. The patient started to recover from symptoms fourth months after transplantation.Conclusions:Tacrolimus is known to have neurotoxic side effects and it may precipitate CPM in patients who have predisposing factors. Sirolimus and steroids should be considered as safe and an effective alternative for immunosuppression in the setting of CPM after liver transplantation.

Zentrale pontine Myelinolyse

One week after relapsing a 44-year-old female alcoholic and drug addict developed a psycho-organic syndrome. Later she had swallowing and speech dysfunctions and became quadriplegic, the result of central pontine myelinolysis. The signs became most marked in the 5th week of illness and then gradually improved, but an independent existence became impossible. There were no electrolyte disorders. Computed tomography demonstrated the typical lesion (a hypodense focus in the pons, 1 cm in diameter) after the 3rd week, findings confirmed by magnetic resonance imaging. The acoustic evoked potentials were unremarkable. An abnormal eye-closure reflex suggested medulla oblongata damage. The diagnosis of central pontine myelinolysis is difficult because the typical brainstem lesions become demonstrable by various imaging techniques only after some delay.

Zentrale pontine Myelinolyse mit hyperintenser Läsion im diffusionsgewichteten MRT: Übersicht anhand eines Fallberichtes

Central pontine myelinolysis (CPM) is a demyelinating disease of the pons often associated with demyelination of other areas of the central nervous system (CNS). The etiology and pathogenesis of this disorder are still not fully understood. However, almost all cases of CPM are related to severe diseases or chronic alcoholism and occur in the setting of rapidly corrected serum hyponatremia and hypotonicity respectively. Depending on the involvement of other CNS structures, the clinical picture can vary considerably. Magnetic resonance imaging is the most sensitive investigation for the antemortem diagnosis of CPM, although the radiological findings lag behind and do not necessarily correlate with the clinical picture. Quite obviously diffusion-weighted imaging can be useful in the rapid diagnosis of CPM. This short review summarizes the current knowledge on the pathogenesis, clinical presentation, radiological findings, prognosis and therapeutic approaches of CPM. Characteristical clinical features and MR-findings including hyperintensity on diffusion-weighted images are illustrated by a typical case.

The possible causes of central pontine myelinolysis after liver transplantation

To sum up the clinical characteristics of patients with central pontine myelinolysis (CPM) after orthotopic liver transplantation (OLT) and to document the possible causes on CPM. 142 patients' data with OLT between January 1999 to May 2003 were analyzed retrospectively. The following risk factors during preoperation were analyzed between patients with and without CPM: primary liver disease, preoperative serum sodium level, magnesium level and plasma osmolality, fluctuation degree of serum sodium concentration, and immunosuppressive drugs level etc. A total of 13 (9.2%) neurologic symptoms appeared in 142 patients post operation, including 5 cases (3.5%) with CPM and 8 cases (5.6%) with cerebral hemorrhage or infarct. 2 patients who developed CPM after OLT had hyponatremia history before operation (serum sodium <130 mmol/L), and the mean serum sodium level was (130.6 +/- 5.54) mmol/L. The serum sodium level was significantly lower in CPM than that of patients without neurologic complication or with cerebral hemorrhage/infarct (P <0.05). The rises of serum sodium perioperative 48 h after OLT in patients with CPM was significantly greater than that in patients with cerebral hemorrhage/infarct or no neurologic complication (19.5 +/- 6.54) mmol/L, (10.1 +/- 6.43) mmol/L, (4.5 +/- 4.34) mmol/L, respectively, (P < 0.05). Plasma osmolality increased greatly postoperatively in patients with CPM. Hypomagnesemia was noted in all patients perioperatively, but there was not significant difference among groups. The duration of operation in CPM was longer than in others (492 +/- 190.05) min (P <0.05). Cyclosporin A (CsA) levels were normal in all patients, but there was significant difference between patients with and without neurologic complication (P <0.05). CPM may be more prevalent following liver transplantation. Although the diagnosis of CPM after OLT can be made by complete neurologic evaluation including magnetic resonance imaging (MRI) of the head, the mortality is still very high. The occurrence of CPM may be associated with hyponatremia, rapid rise of serum sodium concentration, postoperative increase of plasma osmolality, the duration of operation and high CsA levels.

Possible causes of central pontine myelinolysis after liver transplantation.

To sum up the clinical characteristics of patients with central pontine myelinolysis (CPM) after orthotopic liver transplantation (OLT) and to document the possible causes of CPM. Data of 142 patients undergoing OLT between January 1999 to May 2003 were analyzed retrospectively. Following risk factors during perioperation were analyzed in patients with and without CPM: primary liver disease, preoperative serum sodium level, magnesium level and plasma osmolality, fluctuation degree of serum sodium concentration, and immunosuppressive drug level, etc. A total of 13 (9.2%) neurologic symptoms appeared in 142 patients post-operation including 5 cases (3.5%) with CPM and 8 cases (5.6%) with cerebral hemorrhage or infarct. Two patients developing CPM after OLT had a hyponatremia history before operation (serum sodium<130 mmol/L), their mean serum sodium level was 130.6 +/- 5.54 mmol/L. The serum sodium level was significantly lower in CPM patients than in patients without neurologic complications or with cerebral hemorrhage/infarct (P<0.05). The increase in serum sodiumduring perioperative 48 h after OLT in patients with CPM was significantly greater than that in patients with cerebral hemorrhage/infarct but without neurologic complications (19.5 +/- 6.54 mmol/L, 10.1 +/- 6.43 mmol/L, 4.5 +/- 4.34 mmol/L, respectively, P<0.05). Plasma osmolality was greatly increased postoperation in patients with CPM. Hypomagnesemia was noted in all patients perioperation, but there were no significant differences between groups. The duration of operation on patients with CPM was longer than that on others (492 +/- 190.05 min, P<0.05). Cyclosporin A (CsA) levels were normal in all patients, but there were significant differences between patients with or without neurologic complications (P<0.05). CPM may be more prevalent following liver transplantation. Although the diagnosis of CPM after OLT can be made by overall neurologic evaluations including magnetic resonance imaging (MRI) of the head, the mortality is still very high. The occurance of CPM may be associated with such factors as hyponatremia, rapid rise of serum sodium concentration, plasma osmolality increase postoperation, the duration of operation, and high CsA levels.

Central pontine myelinolysis

A 9 year old boy presented with fever, drowsiness, quadriparesis and facial myokymia. MRI showed demyelination in the pontine region. A diagnosis of central pontine myelinolysis was made. Literature review revealed the rarity of uneventful recovery as has been seen in our case.

Asymptomatic pontine lesions found by magnetic resonance imaging: Are they central pontine myelinolysis?

Clinicians occasionally receive radiographic reports noting pontine lesions in their patients who have undergone magnetic resonance imaging (MRI) for symptoms not referable to the pons. Based on these relatively isolated lesions, patients may receive the presumptive radiographic diagnosis of central pontine myelinolysis (CPM). Review of our MRI database from the last five years identified twelve such patients with hyperintense pontine lesions on T2-weighted scans which were out of proportion to supratentorial white matter disease processes and unexplained by the remainder of their radiographic studies. In an attempt to further clarify whether these findings were more consistent with CPM or some other process, we reviewed these patients' clinical records with particular attention to electrolyte disturbances, alcoholism, liver disease and hypertension. We also compared the MRI studies from these twelve patients with four MRI scans from patients with clinically diagnosed CPM and with eight post-mortem MRI scans on autopsy-proven asymptomatic CPM. By comparing pre- and post-mortem scans, five of the twelve unknown pontine lesions were felt to be too large to represent asymptomatic CPM. Five were thought to be incompatible with CPM based on shape and/or discohesiveness; one of these came to autopsy and showed cerebral and pontine ischemic rarefaction, not CPM. Only two of these twelve cases were felt to be asymptomatic or mildly symptomatic CPM, but have not come to autopsy. We conclude that pontine lesions found incidentally on MRI scans are a heterogeneous group, many of which are more consistent with pontine ischemic rarefaction than with asymptomatic CPM.

中心性脳橋融髄症の１症例

A 42-year-old male complained of tremor of the hands and titubation. Neurological and neurotological examinations revealed 1) tremor of the hands, 2) truncal ataxia, 3) mild cerebellar ataxia of the extremities, 4) mild limitation of eye movement to the right, 5) geotropic positional nystagmus, 6) down-beat positioning nystagmus, 7) impairment of horizontal eye movements including smooth pursuit, optokinetic nystagmus (OKN) and vestibulo-ocular reflex (VOR) and 8) absence of stapedial reflex. Among the negative findings, 9) there were no signs of damage of the paramedian pontine reticular formation of the left side, medial longitudinal fasciculus or the abducens nerve, 10) vertical ocular movements were not impaired, 11) pure tone audiometry and auditory brainstem response were normal and 12) the facial muscles were not palsied. T2-weighted images of NMR-CT in the coronary plane revealed a horseshoe-shaped high-signal region extending bilaterally in the central area of the pons. A diagnosis of central pontine myelinolysis (CPM) was made from the clinical course and the NMR-CT findings, but the serum electrolytes were not abnormal. An alcoholic history and malnutrition might have contributed to the development of C PM in this patient. The finding that OKN and VOR were impaired only in the horizontal direction and not in the vertical direction indicates that the vertical eye movement system connecting with the vestibular nucleus (VN) is independent of the horizontal system connecting with the VN.

Central pontine myelinolysis: Diagnosis by computed tomography, magnetic resonance and evoked potentials

The intravital diagnosis of central pontine myelinolysis has become possible with the introduction of computed tomography and magnetic resonance into neurological diagnostics. These tools are of special value when neurological signs of a ventral pontine lesion are lacking, as in the case we describe. Auditory evoked potentials likewise confirm their diagnostic value with regard both to the site of the lesion and to its dorsal extent toward the pontine tegmentum.

CENTRAL PONTINE MYELINOLYSIS

A young pregnant woman showing clinical symptoms of numbness, vertigo, diplopia, and amnesia with associated hypernatremia ran a fulminant course. At autopsy, an area of extensive demyelination in the center of the pons was found and a pathological diagnosis of central pontine myelinolysis was made. Since definitive etiology and pathogenesis of the lesion have not been established, we investigated the role of humoral immunity in the pathogenesis of this condition by retrospective immunofluorescent study; the result was negative. Possible factors related to the etiology and pathogenesis of the lesion in this case are discussed.