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Srichawla BS, Garcia-Dominguez MA. Spectrum of delayed post-hypoxic leukoencephalopathy syndrome: A systematic review. World J Clin Cases 2024; 12:6285-6301. [PMID: 39417054 PMCID: PMC11372523 DOI: 10.12998/wjcc.v12.i29.6285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/31/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Delayed post hypoxic leukoencephalopathy syndrome (DPHLS), also known as Grinker's myelinopathy, is a rare but significant neurological condition that manifests days to weeks after a hypoxic event. Characterized by delayed onset of neurological and cognitive deficits, DPHLS presents substantial diagnostic and therapeutic challenges. AIM To consolidate current knowledge on pathophysiology, clinical features, diagnostic approaches, and management strategies for DPHLS, providing a comprehensive overview and highlighting gaps for future research. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines, we systematically searched PubMed, ScienceDirect and Hinari databases using terms related to delayed post-hypoxic leukoencephalopathy. Inclusion criteria were original research articles, case reports, and case series involving human subjects with detailed clinical, neuroimaging, or pathological data on DPHLS. Data were extracted on study characteristics, participant demographics, clinical features, neuroimaging findings, pathological findings, treatment, and outcomes. The quality assessment was performed using the Joanna Briggs Institute critical appraisal checklist. RESULTS A total of 73 cases were reviewed. Common comorbidities included schizoaffective disorder, bipolar disorder, hypertension, and substance use disorder. The primary causes of hypoxia were benzodiazepine overdose, opioid overdose, polysubstance overdose, and carbon monoxide (CO) poisoning. Symptoms frequently include decreased level of consciousness, psychomotor agitation, cognitive decline, parkinsonism, and encephalopathy. Neuroimaging commonly revealed diffuse T2 hyperintensities in cerebral white matter, sometimes involving the basal ganglia and the globus pallidus. Magnetic resonance spectroscopy often showed decreased N-acetylaspartate, elevated choline, choline-to-creatinine ratio, and normal or elevated lactate. Treatment is often supportive, including amantadine, an antioxidant cocktail, and steroids. Hyperbaric oxygen therapy may be beneficial in those with CO poisoning. Parkinsonism was often treated with levodopa. Most of the patients had substantial recovery over the course of months and many cases had some residual neurocognitive deficits. CONCLUSION DPHLS remains a complex and multifaceted condition with various etiologies and clinical manifestations. Early recognition and appropriate management are crucial to improving patient outcomes. Future research should focus on standardizing diagnostic criteria, using advanced imaging techniques, and exploring therapeutic interventions to improve understanding and treatment of DPHLS. Conducting prospective cohort studies and developing biomarkers for early diagnosis and monitoring will be essential to advance patient care.
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Affiliation(s)
- Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
| | - Maria A Garcia-Dominguez
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
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Zamani N, Osgoei LT, Aliaghaei A, Zamani N, Hassanian-Moghaddam H. Chronic exposure to methadone induces activated microglia and astrocyte and cell death in the cerebellum of adult male rats. Metab Brain Dis 2023; 38:323-338. [PMID: 36287354 DOI: 10.1007/s11011-022-01108-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/13/2022] [Indexed: 02/03/2023]
Abstract
Methadone is a centrally-acting synthetic opioid analgesic widely used in the methadone maintenance therapy (MMT) programs throughout the world. Considering its neurotoxic effects particularly on the cerebellum, this study aims to address the behavioral and histological alterations in the cerebellar cortex associated with methadone administration. Twenty-four adult male albino rats were randomized into two groups of control and methadone treatment. Methadone was subcutaneously administered (2.5-10 mg/kg) once a day for two consecutive weeks. The functional and structural changes in the cerebellum were compared to the control group. Our data revealed that treating rats with methadone not only induced cerebellar atrophy, but also prompted the actuation of microgliosis, astrogliosis, and apoptotic biomarkers. We further demonstrated that treating rats with methadone increased complexity of astrocyte processes and decreased complexity of microglia processes. Our result showed that methadone impaired motor coordination and locomotor performance and neuromuscular activity. Additionally, relative gene expression of TNF-α, caspase-3 and RIPK3 increased significantly due to methadone. Our findings suggest that methadone administration has a neurodegenerative effect on the cerebellar cortex via dysregulation of microgliosis, astrogliosis, apoptosis, and neuro-inflammation.
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Affiliation(s)
- Naghmeh Zamani
- Department of Biology, Faculty of Biological Science, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Laya Takbiri Osgoei
- Department of Microbiology, Faculty of Biological Science, North Tehran Branch, Islamic Azad University, Tehran, Iran.
| | - Abbas Aliaghaei
- Hearing Disorders Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Palis H, Gan W, Xavier C, Desai R, Scow M, Sedgemore KO, Greiner L, Nicholls T, Slaunwhite A. Association of Opioid and Stimulant Use Disorder Diagnoses With Fatal and Nonfatal Overdose Among People With a History of Incarceration. JAMA Netw Open 2022; 5:e2243653. [PMID: 36416821 PMCID: PMC9685494 DOI: 10.1001/jamanetworkopen.2022.43653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Studies have suggested a rise in opioid- and stimulant-involved overdoses in recent years in North America. This risk may be acute for individuals who have had contact with the criminal justice system, who are particularly vulnerable to overdose risk. OBJECTIVE To examine the association of opioid and/or stimulant use disorder diagnoses with overdose (fatal and nonfatal) among people with histories of incarceration. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, population-based health and corrections data were retrieved from the British Columbia Provincial Overdose Cohort, which contains a 20% random sample of residents of British Columbia. The analysis included all people in the 20% random sample who had a history of incarceration between January 1, 2010, and December 31, 2014. Outcomes were derived from 5-years of follow-up data (January 1, 2015, to December 31, 2019). Statistical analysis took place from January 2022 to June 2022. EXPOSURES Substance use disorder diagnosis type (ie, opioid use disorder, stimulant use disorder, both, or neither), sociodemographic, health, and incarceration characteristics. MAIN OUTCOMES AND MEASURES Hazard ratios (HRs) are reported from an Andersen-Gill model for recurrent nonfatal overdose events and from a Fine and Gray competing risk model for fatal overdose events. RESULTS The study identified 6816 people (5980 male [87.7%]; 2820 aged <30 years [41.4%]) with histories of incarceration. Of these, 293 (4.3%) had opioid use disorder only, 395 (6.8%) had stimulant use disorder only, and 281 (4.1%) had both diagnoses. During follow-up, 1655 people experienced 4026 overdoses including 3781 (93.9%) nonfatal overdoses, and 245 (6.1%) fatal overdoses. In adjusted analyses, the hazard of both fatal (HR, 2.39; 95% CI, 1.48-3.86) and nonfatal (HR, 2.45; 95% CI, 1.94-3.11) overdose was highest in the group with both opioid and stimulant use disorder diagnoses. CONCLUSIONS AND RELEVANCE This cohort study of people with a history of incarceration found an elevated hazard of fatal and nonfatal overdose among people with both opioid and stimulant use disorder diagnoses. This study suggests an urgent need to address the service needs of individuals who have had contact with the criminal justice system and who co-use opioids and stimulants.
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Affiliation(s)
- Heather Palis
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wenqi Gan
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington
| | - Chloe Xavier
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Roshni Desai
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Marnie Scow
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kali-olt Sedgemore
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Coalition of Peers Dismantling the Drug War, Vancouver, British Columbia, Canada
| | | | - Tonia Nicholls
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
- BC Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
| | - Amanda Slaunwhite
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Treatment of overdose in the synthetic opioid era. Pharmacol Ther 2021; 233:108019. [PMID: 34637841 DOI: 10.1016/j.pharmthera.2021.108019] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022]
Abstract
Overdose deaths are often viewed as the leading edge of the opioid epidemic which has gripped the United States over the past two decades (Skolnick, 2018a). This emphasis is perhaps unsurprising because opioid overdose is both the number-one cause of death for individuals between 25 and 64 years old (Dezfulian et al., 2021) and a significant contributor to the decline in average lifespan (Dowell et al., 2017). Exacerbated by the COVID 19 pandemic, it was estimated there were 93,400 drug overdose deaths in the United States during the 12 months ending December 2020, with more than 69,000 (that is, >74%) of these fatalities attributed to opioid overdose (Ahmad et al., 2021). However, the focus on mortality statistics (Ahmad et al., 2021; Shover et al., 2020) tends to obscure the broader medical impact of nonfatal opioid overdose. Analyses of multiple databases indicate that for each opioid-induced fatality, there are between 6.4 and 8.4 non-fatal overdoses, exacting a significant burden on both the individual and society. Over the past 7-8 years, there has been an alarming increase in the misuse of synthetic opioids ("synthetics"), primarily fentanyl and related piperidine-based analogs. Within the past 2-3 years, a structurally unrelated class of high potency synthetics, benzimidazoles exemplified by etonitazene and isotonitazene ("iso"), have also appeared in illicit drug markets (Thompson, 2020; Ujvary et al. 2021). In 2020, it was estimated that over 80% of fatal opioid overdoses in the United States now involve synthetics (Ahmad et al., 2021). The unique physicochemical and pharmacological properties of synthetics described in this review are responsible for both the morbidity and mortality associated with their misuse as well as their widespread availability. This dramatic increase in the misuse of synthetics is often referred to as the "3rd wave" (Pardo et al., 2019; Volkow and Blanco, 2020) of the opioid epidemic. Among the consequences resulting from misuse of these potent opioids is the need for higher doses of the competitive antagonist, naloxone, to reverse an overdose. The development of more effective reversal agents such as those described in this review is an essential component of a tripartite strategy (Volkow and Collins, 2017) to reduce the biopsychosocial impact of opioid misuse in the "synthetic era".
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Kitchen SA, McCormack D, Werb D, Caudarella A, Martins D, Matheson FI, Gomes T. Trends and outcomes of serious complications associated with non-fatal opioid overdoses in Ontario, Canada. Drug Alcohol Depend 2021; 225:108830. [PMID: 34182376 DOI: 10.1016/j.drugalcdep.2021.108830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Non-fatal opioid overdoses can lead to serious complications and consequently, long-term health effects. We sought to characterize trends of hospitalizations for serious complications associated with opioid overdoses in Ontario, Canada and report health services utilization and mortality in the year following hospital discharge. METHODS We conducted a cross-sectional study in Ontario among individuals who experienced a hospitalization for a serious complication (required intubation, rhabdomyolysis, or a brain injury) associated with an opioid overdose between 2010 and 2019. We examined inpatient characteristics at the time of hospital admission, and health services utilization and mortality rates in the year following hospital discharge. RESULTS The rate of hospitalizations for serious complications associated with opioid overdoses increased by 66.7 % from 1.8 per 100,000 population in 2010 to 3.0 per 100,000 population in 2019 in Ontario. Individuals that were discharged alive from hospital experienced high health services utilization in the following year; 71.2 % (N = 953 of 1,338) visited the emergency department (ED), 34.2 % (N = 458) were admitted to hospital, and 16.4 % (N = 219) were treated in hospital for an opioid overdose. However only a quarter of individuals (N = 332; 24.8 %) initiated on opioid agonist therapy within 90 days. Additionally, 8.0 % (N = 127) of hospitalizations resulted in death within 1 year. CONCLUSIONS This study highlights increasing rates of serious complications associated with opioid overdoses, with a high demand of health services and a high mortality rate in the following year. These findings highlight an ongoing need for support and harm reduction services to allow for early intervention and follow-up care.
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Affiliation(s)
- Sophie A Kitchen
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Daniel McCormack
- Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Dan Werb
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Division of Infectious Diseases and Global Public Health, UC San Diego, 9500 Gilman Dr, San Diego, CA, 92161, USA; Centre on Drug Policy Evaluation, UC San Diego, 9500 Gilman Dr, San Diego, CA, 92161, USA
| | - Alexander Caudarella
- Mental Health and Addictions Service, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Diana Martins
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Flora I Matheson
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Tara Gomes
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.
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Nicolas-Jilwan M, Almaghrabi RS. Diffuse necrotising leukoencephalopathy with microhaemorrhages in a patient with severe COVID-19 disease. Neuroradiol J 2020; 33:528-531. [PMID: 32928038 PMCID: PMC7788683 DOI: 10.1177/1971400920959324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A wide range of neurological complications of coronavirus disease 2019 (COVID-19) is increasingly recognised. Although the majority of these remain ischaemic and haemorrhagic events, various disorders are being reported. In particular, several cases of diffuse acute leukoencephalopathy have been observed in critically ill patients with COVID-19 disease. We report the case of a 59-year-old man with multiple comorbidities and severe COVID-19 pneumonia who developed a diffuse leukoencephalopathy with microhaemorrhages and extensive associated white matter necrosis. Although this is the first documented case of extensive COVID-19-associated white matter necrosis, we highlight the relatively constant features of this injury similar to previously reported cases, including symmetrical involvement of the supratentorial white matter, sparing of the peripheral subcortical regions except in the precentral gyri, frequently associated microhaemorrhages, relative sparing of the deep gray matter structures and infratentorial structures, and lack of enhancement.
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Affiliation(s)
- Manal Nicolas-Jilwan
- Division of Neuroradiology, King Faisal Specialist Hospital and Research Centre, Saudi Arabia
| | - Reem Saad Almaghrabi
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Saudi Arabia
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Breit H, Jhaveri M, John S. Concomitant delayed posthypoxic leukoencephalopathy and critical illness microbleeds. Neurol Clin Pract 2018; 8:e31-e33. [PMID: 30564507 DOI: 10.1212/cpj.0000000000000513] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/20/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Hannah Breit
- Departments of Neurological Sciences (HB, SJ) and Radiology (MJ), Rush University Medical Center, Chicago, IL
| | - Miral Jhaveri
- Departments of Neurological Sciences (HB, SJ) and Radiology (MJ), Rush University Medical Center, Chicago, IL
| | - Sayona John
- Departments of Neurological Sciences (HB, SJ) and Radiology (MJ), Rush University Medical Center, Chicago, IL
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Ueno K, Takahashi T, Higashima M, Okazaki R, Takano S, Wada Y. Delayed posthypoxic leukoencephalopathy following alcohol and psychotropic drug overdose: a case report. Clin Case Rep 2018; 6:1158-1165. [PMID: 29881586 PMCID: PMC5986050 DOI: 10.1002/ccr3.1544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/17/2018] [Accepted: 04/03/2018] [Indexed: 11/22/2022] Open
Abstract
Delayed posthypoxic leukoencephalopathy (DPHL), a demyelinating syndrome, can easily be misdiagnosed as a psychiatric condition. Our case study shows that magnetic resonance imaging is highly useful for an early diagnosis of DPHL and that vascular endothelial growth factor might be a supplementary biomarker for the early detection of DPHL.
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Affiliation(s)
- Kanji Ueno
- Department of NeuropsychiatryFaculty of Medical SciencesUniversity of FukuiFukuiJapan
| | | | - Masato Higashima
- Department of NeuropsychiatryFaculty of Medical SciencesUniversity of FukuiFukuiJapan
| | - Ryoko Okazaki
- Department of NeuropsychiatryFaculty of Medical SciencesUniversity of FukuiFukuiJapan
| | | | - Yuji Wada
- Department of NeuropsychiatryFaculty of Medical SciencesUniversity of FukuiFukuiJapan
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Steenhoven RV, Karas G, Tan P, Weinstein H. Heroin-Induced Toxic Leukoencephalopathy. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/crcm.2017.68024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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King F, Morris NA, Schmahmann JD. Delayed Posthypoxic Leukoencephalopathy: Improvement with Antioxidant Therapy. Case Rep Neurol 2015; 7:242-6. [PMID: 26955335 PMCID: PMC4777931 DOI: 10.1159/000441892] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Delayed posthypoxic leukoencephalopathy (DPHL) may result from a variety of hypoxic insults, including respiratory depression from an opiate overdose. The underlying pathophysiological mechanism of DPHL remains uncertain. We describe a patient with a typical case of DPHL who responded clinically to antioxidant treatment. Methods Clinical, serological, and radiographic investigations were undertaken in the evaluation of the patient. Results A 63-year-old man developed altered mental status 10 days following recovery from an opiate overdose and aspiration pneumonia that required intubation. The clinical course and brain imaging were consistent with DPHL. Initiation of antioxidant therapy with vitamin E, vitamin C, B-complex vitamins, and coenzyme Q10 coincided with the prompt reversal of clinical deterioration. Conclusions The potential therapeutic effect of antioxidants on DPHL needs to be explored in future cases. If this relationship indeed holds true, it would be consistent with the hypothesis that formation of reactive oxygen species during reperfusion plays a role in the pathophysiology of this disorder.
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Affiliation(s)
- Franklin King
- Department of Psychiatry, Massachusetts General Hospital and McLean Hospital, Boston, Mass., USA
| | - Nicholas A Morris
- Department of Neurology, Columbia Presbyterian Hospital and Cornell Presbyterian Hospital, New York, N.Y., USA
| | - Jeremy D Schmahmann
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass., USA
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Zamora CA, Nauen D, Hynecek R, Ilica AT, Izbudak I, Sair HI, Gujar SK, Pillai JJ. Delayed posthypoxic leukoencephalopathy: a case series and review of the literature. Brain Behav 2015; 5:e00364. [PMID: 26357591 PMCID: PMC4559021 DOI: 10.1002/brb3.364] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/20/2015] [Accepted: 06/07/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Delayed posthypoxic leukoencephalopathy (DPHL) is a rare and underrecognized entity where patients manifest a neurological relapse after initial recovery from an acute hypoxic episode. We sought to describe the magnetic resonance imaging (MRI) findings in a group of patients with DPHL and review the available literature. METHODS Retrospective case series including patients who presented with neurological and/or psychiatric symptoms after recovery from an acute hypoxic episode. The history and clinical presentation were reviewed from the electronic medical records. MRI scans were evaluated from the picture archiving and communication system. We performed a comprehensive review of the English medical literature for prior published cases of DPHL and describe the key imaging findings that have been reported related to this condition. RESULTS A total of five patients were identified, including four patients with respiratory failure due to drug overdoses from benzodiazepines, opioids, and/or barbiturates, and one patient who presented after cardiopulmonary arrest due to pulmonary embolism. All patients showed diffuse, extensive, and confluent white matter signal abnormalities including prominent restricted diffusion, extending to the subcortical white matter and respecting the U-fibers. There was no gyral edema or contrast enhancement. In one case histopathology was available, which highlighted patchy subcortical myelin loss with sparing of U-fibers and demonstrated prominent macrophage/microglial inflammation with extensive axonal damage. Of the other four patients, two were at their neurological baselines and two had persistent neurological deficits at the time of discharge. CONCLUSIONS The described constellation of MRI findings is highly suggestive of DPHL in the appropriate clinical setting.
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Affiliation(s)
- Carlos A Zamora
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - David Nauen
- Department of Pathology, Johns Hopkins University School of Medicine 600 N Caroline St, Baltimore, MD, 21287
| | - Robert Hynecek
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - Ahmet T Ilica
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - Izlem Izbudak
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - Haris I Sair
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - Sachin K Gujar
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
| | - Jay J Pillai
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine 601 N Caroline St, Baltimore, MD, 21287
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Yoo IS, Lee SH, Suk SH. A Case of Fentanyl Intoxication and Delayed Hypoxic Leukoencephalopathy Caused by Incidental Use of Fentanyl Patch in a Healthy Elderly Man. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.1.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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