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Osmotic myelinolysis: Does extrapontine myelinolysis precede central pontine myelinolysis? Report of two cases and review of literature.

Babanrao SA, Prahladan A, Kalidos K, Ramachandran K - Indian J Radiol Imaging (2015 Apr-Jun)

Bottom Line: This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge.We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop.This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.

View Article: PubMed Central - PubMed

Affiliation: Department of Imageology, Regional Cancer Centre, Trivandrum, Kerala, India.

ABSTRACT
Osmotic myelinolysis is an acute, rare, demyelinating process. After the initial description of the condition by Adam and colleagues in 1959, many case series have been published describing the central and extrapontine myelinolysis. Imaging has a definitive role in establishing the diagnosis of osmotic myelinolysis in vivo and diffusion-weighted imaging reveals earliest changes in affected brain parenchyma. We report two cases of patients with proven malignancy who developed extrapontine myelinolysis after treatment for hyponatremia and progressed to central pontine myelinolysis within a week. This was confirmed with magnetic resonance (MR) imaging and clinical assessment. This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge. An early MRI of the brain in suspected/high-risk cases of osmotic myelinolysis may show features of extrapontine myelinolysis in the form of restricted diffusion in bilateral basal ganglia and may serve as a guide for predicting progression, prognosticating and deciding further treatment of pontine myelinolysis. We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop. This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.

No MeSH data available.


Related in: MedlinePlus

Case 2 (2nd MRI - 9 days after correction of hyponatremia) (A) Axial FLAIR section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (B) Axial DWI section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (C) Axial ADC map at the level of basal ganglia shows high ADC values suggestive of decreased diffusion restriction and T2 shine through effect (D) Axial FLAIR section at the level of pons shows trident-shaped hyperintensity within central pons (E) Axial DWI section at the level of pons shows strong diffusion restriction in pons (trident-shaped) (F) Axial ADC map at the level of pons shows low ADC values suggestive of strong diffusion restriction (central pontine myelinolysis)
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Figure 4: Case 2 (2nd MRI - 9 days after correction of hyponatremia) (A) Axial FLAIR section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (B) Axial DWI section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (C) Axial ADC map at the level of basal ganglia shows high ADC values suggestive of decreased diffusion restriction and T2 shine through effect (D) Axial FLAIR section at the level of pons shows trident-shaped hyperintensity within central pons (E) Axial DWI section at the level of pons shows strong diffusion restriction in pons (trident-shaped) (F) Axial ADC map at the level of pons shows low ADC values suggestive of strong diffusion restriction (central pontine myelinolysis)

Mentions: The hyperintense signals had increased in size and intensity in comparison to previous MRI. The thalami were now involved. On T1W imaging, the lesions were hypointense. The entire altered signal intensity area showed no evidence of restricted diffusion. New lesions showing strong diffusion restriction were seen in the pons, showing trident or bat wing appearance. Rest of the cerebral or cerebellar parenchyma was normal [Figure 4]. MRI diagnosis of CPM was given.


Osmotic myelinolysis: Does extrapontine myelinolysis precede central pontine myelinolysis? Report of two cases and review of literature.

Babanrao SA, Prahladan A, Kalidos K, Ramachandran K - Indian J Radiol Imaging (2015 Apr-Jun)

Case 2 (2nd MRI - 9 days after correction of hyponatremia) (A) Axial FLAIR section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (B) Axial DWI section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (C) Axial ADC map at the level of basal ganglia shows high ADC values suggestive of decreased diffusion restriction and T2 shine through effect (D) Axial FLAIR section at the level of pons shows trident-shaped hyperintensity within central pons (E) Axial DWI section at the level of pons shows strong diffusion restriction in pons (trident-shaped) (F) Axial ADC map at the level of pons shows low ADC values suggestive of strong diffusion restriction (central pontine myelinolysis)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4419428&req=5

Figure 4: Case 2 (2nd MRI - 9 days after correction of hyponatremia) (A) Axial FLAIR section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (B) Axial DWI section at the level of basal ganglia shows hyperintense signal in both caudate heads and putamina as well as in thalami (C) Axial ADC map at the level of basal ganglia shows high ADC values suggestive of decreased diffusion restriction and T2 shine through effect (D) Axial FLAIR section at the level of pons shows trident-shaped hyperintensity within central pons (E) Axial DWI section at the level of pons shows strong diffusion restriction in pons (trident-shaped) (F) Axial ADC map at the level of pons shows low ADC values suggestive of strong diffusion restriction (central pontine myelinolysis)
Mentions: The hyperintense signals had increased in size and intensity in comparison to previous MRI. The thalami were now involved. On T1W imaging, the lesions were hypointense. The entire altered signal intensity area showed no evidence of restricted diffusion. New lesions showing strong diffusion restriction were seen in the pons, showing trident or bat wing appearance. Rest of the cerebral or cerebellar parenchyma was normal [Figure 4]. MRI diagnosis of CPM was given.

Bottom Line: This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge.We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop.This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.

View Article: PubMed Central - PubMed

Affiliation: Department of Imageology, Regional Cancer Centre, Trivandrum, Kerala, India.

ABSTRACT
Osmotic myelinolysis is an acute, rare, demyelinating process. After the initial description of the condition by Adam and colleagues in 1959, many case series have been published describing the central and extrapontine myelinolysis. Imaging has a definitive role in establishing the diagnosis of osmotic myelinolysis in vivo and diffusion-weighted imaging reveals earliest changes in affected brain parenchyma. We report two cases of patients with proven malignancy who developed extrapontine myelinolysis after treatment for hyponatremia and progressed to central pontine myelinolysis within a week. This was confirmed with magnetic resonance (MR) imaging and clinical assessment. This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge. An early MRI of the brain in suspected/high-risk cases of osmotic myelinolysis may show features of extrapontine myelinolysis in the form of restricted diffusion in bilateral basal ganglia and may serve as a guide for predicting progression, prognosticating and deciding further treatment of pontine myelinolysis. We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop. This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.

No MeSH data available.


Related in: MedlinePlus