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Griffin K, Stitt D. Opioid-Associated Nervous System Injuries. Semin Neurol 2024. [PMID: 38848747 DOI: 10.1055/s-0044-1787545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
With the rise of the opioid epidemic, the practicing neurologist must recognize the patterns of a growing number of opioid-associated neurological injuries. This is in addition to the classic toxidrome of miosis, altered mental status, and respiratory depression, which must never be overlooked, as it is reversible and potentially lifesaving. Several other idiosyncratic syndromes due to opioid-related nervous system insults are defined by their characteristic imaging findings and portend variable functional recovery. Opioid toxicity can not only lead to brain injury, but also spinal cord and, rarely, peripheral nerve injury. As several newer synthetic opioids are undetectable by most assays, a low threshold to suspect opioid exposure must be maintained.
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Affiliation(s)
- Kim Griffin
- Department of Neurology, Mayo Clinic, Rochester, New York
| | - Derek Stitt
- Department of Neurology, Mayo Clinic, Rochester, New York
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2
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Koenigsberg RA, Ross L, Timmerman J, Surineni R, Breznak K, Loven TC. Case of pediatric cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome in a 2-year-old girl. Pediatr Radiol 2024; 54:1220-1223. [PMID: 38630282 PMCID: PMC11182809 DOI: 10.1007/s00247-024-05928-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 06/19/2024]
Abstract
Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome is a recently described entity that refers to a specific pattern of cerebellar edema with restricted diffusion and crowding of the fourth ventricle among other findings. The syndrome is commonly associated with toxic opioid exposure. While most commonly seen in adults, we present a case of a 2-year-old girl who survived characteristic history and imaging findings of CHANTER syndrome.
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Affiliation(s)
- Robert A Koenigsberg
- Department of Radiology, Temple University Hospital, Philadelphia, PA, USA
- Saint Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Luke Ross
- Department of Radiology, Temple University Hospital, Philadelphia, PA, USA.
| | - Jason Timmerman
- Department of Radiology, Temple University Hospital, Philadelphia, PA, USA
| | - Rithika Surineni
- Department of Radiology, Temple University Hospital, Philadelphia, PA, USA
| | - Kara Breznak
- Saint Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Tina C Loven
- Saint Christopher's Hospital for Children, Philadelphia, PA, USA
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3
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Venkatraman S, Mehta T, Deng F. A Rare Neurotoxicity Syndrome Following Opioid Intoxication. Ann Neurol 2024. [PMID: 38742664 DOI: 10.1002/ana.26953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/01/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Siddharth Venkatraman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tej Mehta
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Francis Deng
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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4
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Eden CO, Alkhalaileh DS, Pettersson DR, Hunter AJ, Arastu AH. Clinical and neuroradiographic features of fentanyl inhalation-induced leukoencephalopathy. BMJ Case Rep 2024; 17:e258395. [PMID: 38684340 PMCID: PMC11103052 DOI: 10.1136/bcr-2023-258395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 05/02/2024] Open
Abstract
A man in his late 40s with no known past medical history was unresponsive for an unknown period of time. Crushed pills and white residue were found on a nearby table. On presentation he was obtunded and unresponsive to verbal commands but withdrawing to painful stimuli. The initial urine drug screen was negative, but a urine fentanyl screen was subsequently positive with a level of 137.3 ng/mL. MRI of the brain showed reduced diffusivity and fluid attenuated inversion recovery (FLAIR) hyperintensity symmetrically in the bilateral supratentorial white matter, cerebellum and globus pallidus. Alternative diagnoses such as infection were considered, but ultimately the history and workup led to a diagnosis of fentanyl-induced leukoencephalopathy. Three days after admission the patient became able to track, respond to voice and follow basic one-step commands. The patient does not recall the mechanism of inhalation. While there are case reports of heroin-induced leukoencephalopathy following inhaled heroin use and many routes of fentanyl, this is the first reported case of a similar phenomenon due to fentanyl inhalation.
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Affiliation(s)
- Christopher O Eden
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Duna S Alkhalaileh
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David R Pettersson
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Alan J Hunter
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Asad H Arastu
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
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5
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Jingami N, Cho K, Nitta T, Takatani M, Kobayashi K, Takenaka R, Sugita N, Ohtsuru S. Case report: Consecutive hyperbaric oxygen therapy for delayed post-hypoxic leukoencephalopathy resulting from CHANTER syndrome caused by opioid intoxication. Front Med (Lausanne) 2024; 11:1364038. [PMID: 38695031 PMCID: PMC11061434 DOI: 10.3389/fmed.2024.1364038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/01/2024] [Indexed: 05/04/2024] Open
Abstract
Delayed post-hypoxic leukoencephalopathy (DPHL) is a poorly recognized syndrome characterized by neuropsychiatric symptoms following recovery from an acute hypoxic episode. Although most cases are related to carbon monoxide poisoning, some have been linked to excessive opioid use. Opioid intoxication has recently become known for manifesting the characteristic imaging findings involving cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome. Herein, we present a patient with severe disturbances in consciousness who was initially diagnosed with CO poisoning but was later found to have taken excessive tramadol. Magnetic resonance imaging (MRI) in the acute phase revealed abnormal intensities in the bilateral globus pallidus and the cerebellum, indicative of CHANTER syndrome. After intensive care, his level of consciousness was restored. However, around the 3rd week after hospitalization, his consciousness gradually deteriorated and he developed severe neurological symptoms. Another MRI on day 25 revealed a new diffuse white matter abnormality; DPHL was suspected. Cerebrospinal fluid collected on day 28 revealed significantly elevated myelin basic protein levels. Although it was challenging to decide on a treatment plan, hyperbaric oxygen (HBO) therapy trials were initiated on day 58; the patient's condition improved after a series of HBO sessions. MRI revealed gradual shrinkage of the white matter abnormality. A total of 63 consecutive HBO sessions were performed, leading to the successful resolution of the serious neurological symptoms. While the effectiveness of HBO therapy for DPHL remains inconclusive, especially in opioid-related cases, this patient made a remarkable recovery, likely due to the therapeutic effect of improved cerebral blood flow and oxygenation.
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Affiliation(s)
- Naoto Jingami
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Hyperbaric Oxygen Therapy Center, Kyoto University Hospital, Kyoto, Japan
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kosai Cho
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Nitta
- Hyperbaric Oxygen Therapy Center, Kyoto University Hospital, Kyoto, Japan
| | - Miwa Takatani
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryo Takenaka
- Department of Psychiatry, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naoko Sugita
- Department of Psychiatry, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Hyperbaric Oxygen Therapy Center, Kyoto University Hospital, Kyoto, Japan
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6
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Lakhani DA, Deng F. A young man with amnesia after drug overdose. Eur J Intern Med 2024; 122:117-118. [PMID: 38403538 DOI: 10.1016/j.ejim.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/11/2024] [Indexed: 02/27/2024]
Affiliation(s)
- Dhairya A Lakhani
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Francis Deng
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Suthar PP, Hughes K, Mafraji M, Akyuz M, Jhaveri M, Dua SG. Case 324: CHANTER Syndrome. Radiology 2024; 311:e222748. [PMID: 38687220 DOI: 10.1148/radiol.222748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
HISTORY A 69-year-old right-handed man with a history of substance use disorder, hypertension, and diabetes presented to the emergency department in an unresponsive state. Upon examination, apart from tachycardia (heart rate, 108 beats per minute), vital signs were within normal ranges (blood pressure, 134/102 mm Hg; temperature, 97.9 ºF (36.6 ºC); respiratory rate, 16 per minute; oxygen saturation, 96%). The patient had a Glasgow coma scale score of 8. Otherwise, the physical examination revealed no abnormalities. Prior psychiatric and surgical histories were unremarkable. There was no history of recent travel, camping, hiking, or vaccination. No family history could be obtained. Laboratory work-up revealed an elevated creatine kinase level (49 006 U/L [818.4 μkat/L]; normal reference range, 10-205 U/L [0.17-3.42 μkat/L]). An electrocardiogram showed sinus tachycardia without evidence of cardiac ischemia. An echocardiogram was unremarkable. Alanine aminotransferase (126 U/L [2.10 μkat/L]; normal reference range, 0-40 U/L [0-0.67 μkat/L]) and aspartate aminotransferase (488 U/L [8.15 μkat/L]; normal reference range, 3-44 U/L [0.05-0.74 μkat/L]) levels were elevated. Polymerase chain reaction results were negative for HIV-1, HIV-2, syphilis treponemal, and COVID-19 antibodies. The remaining routine laboratory work-up findings were within normal limits. Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines. Naloxone was administered, but the patient remained unresponsive. Intubation was performed for airway protection. Noncontrast and contrast-enhanced CT of the head and CT angiography were performed in the emergency department to rule out an acute intracranial abnormality. Multisequence MRI of the brain with administration of intravenous contrast material was ordered for further assessment. CT of the abdomen and pelvis was unremarkable (images not shown).
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Affiliation(s)
- Pokhraj Prakashchandra Suthar
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Kathryn Hughes
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Mustafa Mafraji
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Melih Akyuz
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Miral Jhaveri
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Sumeet G Dua
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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8
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Pandit R, Hamki O, Gaddamanugu S. Cerebellar, Hippocampal, and Basal Nuclei Transient Edema With Restricted Diffusion (CHANTER) Syndrome: Radiologic Features and Findings. Korean J Radiol 2024; 25:314-318. [PMID: 38413115 PMCID: PMC10912496 DOI: 10.3348/kjr.2023.1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/14/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- Renu Pandit
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Omar Hamki
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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9
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Rizkallah Alves B, Rubin DB. Teaching NeuroImage: CHANTER Syndrome. Neurology 2023; 101:e2338-e2339. [PMID: 37813578 PMCID: PMC10727215 DOI: 10.1212/wnl.0000000000207907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/22/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Beatriz Rizkallah Alves
- From the Mass General Brigham Salem Hospital (B.R.A.); and Massachusetts General Hospital (D.R.), Boston.
| | - Daniel B Rubin
- From the Mass General Brigham Salem Hospital (B.R.A.); and Massachusetts General Hospital (D.R.), Boston
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10
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Yurtsever C, Harris J, Breeser A, Ramachandran S, Pisinski L. CHANTER Syndrome and mesenteric ischemia presenting concurrently, a case report and literature review. Radiol Case Rep 2023; 18:4167-4171. [PMID: 37732003 PMCID: PMC10507576 DOI: 10.1016/j.radcr.2023.08.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/22/2023] Open
Abstract
We present a case of a 70-year-old male who was brought to the hospital with altered mental status and was found to have 2 serious complications of cocaine use which are Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome and mesenteric ischemia. CHANTER syndrome is a recently described constellation of radiologic and clinical findings and has a strong association with opiates, and/or other drugs of abuse, including cocaine. Even though CHANTER has many similarities with other ischemic, anoxic, and/or toxic injuries related to substance abuse such as clinical presentation and restricted diffusion on magnetic resonance imaging (MRI); the typical distribution of affected regions in the brain is helpful in differentiating from other injuries. With this study, we aim to emphasize the clues that separate CHANTER syndrome from other acute neurologic problems in the setting of substance use. Our case also suggests that the obstructive hydrocephalus, a known possible complication of CHANTER, is likely seen in the cases with severe and central cerebellar involvement. Additionally, it is not common to see complications in 2 different systems concurrently and a multisystemic approach is crucial to a patient with cocaine use to prevent missed life-threatening consequences throughout the various body systems.
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Affiliation(s)
- Cagri Yurtsever
- Department of Radiology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Jessica Harris
- Department of Radiology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Alex Breeser
- Department of Radiology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Sudha Ramachandran
- Department of Radiology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Leszek Pisinski
- Department of Radiology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
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11
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Atac MF, Vilanilam GK, Damalcheruvu PR, Pandey I, Vattoth S. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome in the setting of opioid and phencyclidine use. Radiol Case Rep 2023; 18:3496-3500. [PMID: 37554665 PMCID: PMC10405156 DOI: 10.1016/j.radcr.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 08/10/2023] Open
Abstract
Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome is a constellation of specific imaging findings characterized by cytotoxic edema in the bilateral hippocampi, cerebellar cortices, and basal ganglia in patients presenting with altered mental status in the setting of substance intoxication. Previous case reports have demonstrated a strong correlation between CHANTER syndrome and polysubstance abuse, particularly with opioid intoxication. The patient we present in this case was found unresponsive following opioid use and demonstrated a constellation of findings on initial and follow-up imaging, consistent with CHANTER syndrome. While cases of irreversible brain damage or death during hospitalization have been reported in the literature, our patient demonstrated near-full recovery a few days after admission to the hospital. We aim to highlight the presentation and progression of CHANTER syndrome and alert clinicians and radiologists to include this entity in their diagnostic checklist for patients with polysubstance abuse and altered mental status.
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Affiliation(s)
- Muhammed F. Atac
- Division of Neuroradiology, Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St., Slot 556, Little Rock, AR, 72205 USA
| | - George K. Vilanilam
- Division of Neuroradiology, Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St., Slot 556, Little Rock, AR, 72205 USA
| | - Prashanth Reddy Damalcheruvu
- Division of Neuroradiology, Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St., Slot 556, Little Rock, AR, 72205 USA
| | - Ishan Pandey
- Pre Medicine Professional Track, Baylor University, Waco, TX, 76706, USA
| | - Surjith Vattoth
- Division of Neuroradiology, Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St., Slot 556, Little Rock, AR, 72205 USA
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12
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Sheehan J, Reynolds A, O'Donnell MM, O'Donohoe R, Tubridy N. Reversible amnesia following opiate overdose: CHANTER syndrome. Pract Neurol 2023; 23:350-351. [PMID: 37068933 DOI: 10.1136/pn-2023-003724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/19/2023]
Affiliation(s)
- Julie Sheehan
- General Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Audrey Reynolds
- General Medicine, St Vincent's University Hospital, Dublin, Ireland
| | | | - Rory O'Donohoe
- General Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Niall Tubridy
- Neurology, St Vincent's University Hospital, Dublin, Ireland
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13
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McConnell E, Bai J. Hippocampal and Cerebellar Involvement in Opioid-Associated Amnestic Syndrome: A Unique Case Report. Cureus 2023; 15:e44248. [PMID: 37772208 PMCID: PMC10524798 DOI: 10.7759/cureus.44248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
We present a case of opioid-associated amnestic syndrome (OAS) in a 46-year-old female with persistent acute anterograde amnesia and biochemically confirmed with fentanyl use. The brain Magnetic Resonance Imaging (MRI) examination demonstrated symmetric restricted diffusion and T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities in the hippocampi and cerebellum. While cases of cerebellar findings in OAS are rare in the literature, this is a unique case with corresponding images that demonstrate cerebellar involvement in addition to the more common hippocampal finding.
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Affiliation(s)
- Evan McConnell
- Imaging Science, University of Rochester Medical Center, Rochester, USA
| | - James Bai
- Imaging Science, University of Rochester Medical Center, Rochester, USA
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14
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Abstract
OBJECTIVE This article informs and updates the practicing neurologist on the current landscape of known neurologic injuries linked to the use of illicit drugs, focusing on emerging agents. LATEST DEVELOPMENTS Synthetic opioids such as fentanyl and similar derivatives have exploded in prevalence, becoming the leading cause of overdose fatalities. The higher potency of synthetic opioids compared with semisynthetic and nonsynthetic opiates poses an increased risk for unintentional overdose when found as an adulterant in other illicit drug supplies such as heroin. Conversely, misinformation about the risk of symptomatic exposure to fentanyl through casual contact with the skin and ambient air has led to misdirected fear and stigma that threatens to impede valid harm-reduction measures for fentanyl users at risk of actual overdose. Finally, during the COVID-19 pandemic, overdose rates and deaths continued to climb, especially among those who use opioids and methamphetamine. ESSENTIAL POINTS A variety of potential neurologic effects and injuries can occur with illicit drug use owing to the diverse properties and mechanisms of action of the various classes. Many high-risk agents are not detected on standard drug screens, including so-called designer drugs, and the practicing neurologist is best served by recognizing the clinical features of the traditional toxidrome and other potential idiosyncratic effects of various illicit agents.
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Saji AS, Raza MH, Anjum AS, Maqsood H, Yousaf J, Saleem S. Carbon monoxide poisoning with an atypical presentation on MRI: Case report and literature review. Ann Med Surg (Lond) 2022; 82:104655. [PMID: 36268296 PMCID: PMC9577589 DOI: 10.1016/j.amsu.2022.104655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Case presentation Conclusion Acute carbon monoxide poisoning can present with altered mentation, loss of consciousness, and other symptoms. MRI is also crucial in detecting hypoxic-ischemic encephalopathy due to CO poisoning and has established superiority over CT scans. MRI should be included as a diagnostic workup for suspected CO poisoning patients to evaluate hypoxic-ischemic encephalopathy. This will not only aid in the correct diagnosis but will also help in guiding the correct management of the patients.
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Affiliation(s)
- Alen Sam Saji
- West China School of Medicine, Sichuan University, China
| | | | | | - Hamza Maqsood
- Nishtar Medical University and Hospital, Multan, Pakistan
- Corresponding author.
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16
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Mallikarjun KS, Parsons MS, Nigogosyan Z, Goyal MS, Eldaya RW. Neuroimaging Findings in CHANTER Syndrome: A Case Series. AJNR Am J Neuroradiol 2022; 43:1136-1141. [PMID: 35798385 PMCID: PMC9575414 DOI: 10.3174/ajnr.a7569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/13/2022] [Indexed: 11/07/2022]
Abstract
Recently, a distinct clinicoradiologic entity involving cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) on MR imaging was identified. Patients present in an unresponsive state following exposure to drugs of abuse. Very little information exists regarding this entity, particularly in the radiology literature. We identify and describe 3 patients at our institution with similar clinical and radiographic findings. Multifocal restricted diffusion in the brain is typically associated with poor outcomes. By contrast, CHANTER involves intraventricular obstructive hydrocephalus that, when treated, can lead to substantial recovery. This novel syndrome should be on the differential in patients who present in an unresponsive state after recent opioid use in the context of the above imaging findings. Additional diagnoses on the differential can include ischemic stroke, hypoxic-ischemic encephalopathy, "chasing the dragon," leukoencephalopathy, opioid-associated amnestic syndrome, and pediatric opioid-use-associated neurotoxicity with cerebellar edema.
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Affiliation(s)
- K S Mallikarjun
- From the Mallinckrodt Institute of Radiology (K.S.M., M.S.P., Z.N., M.S.G., R.W.E.), Washington University School of Medicine, Ringgold Standard Institution, St. Louis, Missouri
| | - M S Parsons
- From the Mallinckrodt Institute of Radiology (K.S.M., M.S.P., Z.N., M.S.G., R.W.E.), Washington University School of Medicine, Ringgold Standard Institution, St. Louis, Missouri
| | - Z Nigogosyan
- From the Mallinckrodt Institute of Radiology (K.S.M., M.S.P., Z.N., M.S.G., R.W.E.), Washington University School of Medicine, Ringgold Standard Institution, St. Louis, Missouri
| | - M S Goyal
- From the Mallinckrodt Institute of Radiology (K.S.M., M.S.P., Z.N., M.S.G., R.W.E.), Washington University School of Medicine, Ringgold Standard Institution, St. Louis, Missouri
| | - R W Eldaya
- From the Mallinckrodt Institute of Radiology (K.S.M., M.S.P., Z.N., M.S.G., R.W.E.), Washington University School of Medicine, Ringgold Standard Institution, St. Louis, Missouri.,MD Anderson Cancer Center, Diagnostic Imaging Division (R.W.E.), Houston, Texas
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17
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Zhou YMJ, Shah M, Fayngersh A. A Case of Cerebellar Hippocampal and Basal Nuclei Transient Edema With Restricted Diffusion Syndrome With Poor Clinical Outcome. Cureus 2022; 14:e22767. [PMID: 35371879 PMCID: PMC8971074 DOI: 10.7759/cureus.22767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/08/2022] Open
Abstract
Cerebellar hippocampal and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome is a specific pattern of restricted diffusion in the hippocampi and cerebellum identified on brain imaging by clinicians in patients who present with altered mental status in the context of substance intoxication. These patients developed obstructive hydrocephalus a couple of days into their hospitalization that required therapy with osmotic agents and/or surgical interventions (i.e., drains and decompressive craniectomy). In prior cases published, many of the patients had good recovery. The case we present is of a woman who presented after polysubstance use and was found to have brain imaging findings supportive of CHANTER syndrome. Although she was treated with aggressive osmotic therapy and surgical interventions, she ultimately developed irreversible brain damage leading to an overall poor prognosis for recovery. Our case suggests variability in the progression of the syndrome and demonstrates the need for further studies to examine whether the substance of use and the patient’s chronic medical conditions may contribute to the degree of recovery.
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Winstanley EL, Mahoney JJ, Castillo F, Comer SD. Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review. Drug Alcohol Depend 2021; 226:108838. [PMID: 34271512 PMCID: PMC8889511 DOI: 10.1016/j.drugalcdep.2021.108838] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans. METHODS PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized. RESULTS Seventy-nine journal articles, published between 1973-2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders. CONCLUSIONS Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA,Corresponding author at: West Virginia University, School of Medicine, Rockefeller Neuroscience Institute, Department of Behavioral Medicine and Psychiatry, 930 Chestnut Ridge Road, Morgantown, WV 26505, USA. (E.L. Winstanley)
| | - James J. Mahoney
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA
| | - Felipe Castillo
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
| | - Sandra D. Comer
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
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Ahmed U, Wilson R, Hung SC. Bilateral cerebellar hemorrhagic infarcts as an early presentation following opioid-induced toxic encephalopathy in an adult patient. Radiol Case Rep 2021; 16:1207-1210. [PMID: 33815643 PMCID: PMC8010571 DOI: 10.1016/j.radcr.2021.02.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 11/27/2022] Open
Abstract
In the midst of the national opioid crisis, it is necessary for emergency physicians and radiologists to be familiar with presentations of opioid-related complications. We describe a case report of a 51-year-old female who developed bilateral cerebellar hemorrhages following opioid and benzodiazepine overdose. Malignant cerebellar edema is a rare but recognized complication following opiate overdose in children or chronic heroin toxicity. However, acute cerebellar involvement is rarely reported in adults. We feel that clinicians and radiologists should keep in mind the possibility of opioid toxic encephalopathy in their differential for adults with acute bilateral cerebellar infarcts and/or hemorrhages.
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Affiliation(s)
- Umer Ahmed
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Robert Wilson
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sheng-Che Hung
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Barash JA, Whitledge J, Watson CJ, Boyle K, Lim C, Lev MH, DeMaria A, Ganetsky M. Opioid-associated amnestic syndrome: Description of the syndrome and validation of a proposed definition. J Neurol Sci 2020; 417:117048. [PMID: 32739497 DOI: 10.1016/j.jns.2020.117048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE An opioid-associated amnestic syndrome (OAS) characterized by acute onset memory loss and bilateral hippocampal signal abnormalities on brain imaging in the setting of a history of opioid use, most notably fentanyl, has been reported. To date, however, there is no case definition to assist neurologists and other clinicians in identifying this syndrome. A multi-disciplinary collaboration of physicians, including neurologists, propose diagnostic criteria for OAS using cases that have been published in the medical literature or presented at conferences. METHODS Cases were classified as confirmed, probable, or possible based on brain imaging findings and history or analytical testing supporting opioid use. Published articles and presentations were identified by discussion with public health authorities and a systematic search of PubMed. Included were articles, abstracts or posters through November 2019 that presented case reports or case series of a new-onset amnestic syndrome associated with bilateral hippocampal injury on imaging and/or prior opioid or other substance use. The percentages of cases that would meet confirmed, probable, or possible criteria were calculated. RESULTS Twenty-three publications from all sources met criteria for inclusion, accounting for 40 unique cases. Based on the case definition of OAS, 50% (20/40) were confirmed, 25% (10/40) were probable and 25% (10/40) were possible. CONCLUSION The development of a validated, formal case definition for OAS can assist neurologists and other clinicians in evaluating patients with amnesia and a history of opioid use.
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Affiliation(s)
- Jed A Barash
- Department of Medicine, Soldiers' Home, Chelsea, MA, USA.
| | - James Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C James Watson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chun Lim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Alfred DeMaria
- Massachusetts Department of Public Health, Jamaica, Plain, MA, USA
| | - Michael Ganetsky
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Kim DD, Prasad AN. Clinical and radiologic features of pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome. Neurology 2020; 94:710-712. [PMID: 32198237 DOI: 10.1212/wnl.0000000000009293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/26/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Dongkyung Kim
- From the Department of Clinical Neurological Sciences (D.D.K., A.N.P.), Western University, London, ON, Canada; and Division of Paediatric Neurology (A.N.P.), Department of Pediatrics, Western University, London, ON, Canada.
| | - Asuri Narayan Prasad
- From the Department of Clinical Neurological Sciences (D.D.K., A.N.P.), Western University, London, ON, Canada; and Division of Paediatric Neurology (A.N.P.), Department of Pediatrics, Western University, London, ON, Canada
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Jasne AS, Alsherbini KA, Smith MS, Kuohn LR, Pandhi A, Vagal A, Kanter DS. Response to "Malignant cerebella edema in three-year-old girl following accidental opioid ingestion and fentanyl administration". Neuroradiol J 2020; 33:158. [PMID: 32013696 DOI: 10.1177/1971400920903106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Adam S Jasne
- Department of Neurology, Yale School of Medicine, USA
| | - Khalid A Alsherbini
- Department of Neurology and Neurosurgery, University of Tennessee Health Sciences Center, USA
| | - Matthew S Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science, USA
| | - Achala Vagal
- Department of Radiology, University of Cincinnati, USA
| | - Daniel S Kanter
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
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