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Rajiah PS, Suman G, Vijay K, Venugopal N, Mansoori B, Chalian M, Agarwal AK. Multisystem Imaging Manifestations of Kidney Failure. Radiographics 2024; 44:e230124. [PMID: 39052499 DOI: 10.1148/rg.230124] [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: 07/27/2024]
Abstract
Kidney failure (KF) refers to a progressive decline in glomerular filtration rate to below 15 ml/min per 1.73 m2, necessitating renal replacement therapy with dialysis or renal transplant. The hemodynamic and metabolic alterations in KF combined with a proinflammatory and coagulopathic state leads to complex multisystemic complications. The imaging hallmark of systemic manifestations of KF is bone resorption caused by secondary hyperparathyroidism. Other musculoskeletal complications include brown tumor, osteosclerosis, calcinosis, soft-tissue calcification, and amyloid arthropathy. Cardiovascular complications and infections are the leading causes of death in KF. Cardiovascular complications include accelerated atherosclerosis, cardiomyopathy, pericarditis, myocardial calcinosis, and venous thromboembolism. Neurologic complications such as encephalopathy, osmotic demyelination, cerebrovascular disease, and opportunistic infections are also frequently encountered. Pulmonary complications include edema and calcifications. Radiography and CT are used in assessing musculoskeletal and thoracic complications, while MRI plays a key role in assessing neurologic and cardiovascular complications. CT iodinated contrast material is generally avoided in patients with KF except in situations where the benefit of contrast-enhanced CT outweighs the risks and in patients already undergoing maintenance dialysis. At MRI, group II gadolinium-based contrast material can be safely administered in patients with KF. The authors discuss the extrarenal systemic manifestations of KF, the choice of imaging modality in their assessment, and imaging findings of complications. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Prabhakar Shantha Rajiah
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Garima Suman
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Kanupriya Vijay
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Nitin Venugopal
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Bahar Mansoori
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Majid Chalian
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Amit Kumar Agarwal
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
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Greco F, Buoso A, Cea L, D’Andrea V, Bernetti C, Beomonte Zobel B, Mallio CA. Magnetic Resonance Imaging in Uremic Encephalopathy: Identifying Key Imaging Patterns and Clinical Correlations. J Clin Med 2024; 13:4092. [PMID: 39064132 PMCID: PMC11278456 DOI: 10.3390/jcm13144092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/07/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Magnetic Resonance Imaging (MRI) is essential in diagnosing neurological conditions, offering detailed insights into brain pathology. Uremic encephalopathy (UE) is a severe neurological disorder resulting from renal failure, characterized by cognitive impairments and brain abnormalities due to the accumulation of uremic toxins (UTs). Despite extensive research on UTs, there is a significant gap in the detailed characterization of MRI findings in UE patients. This study aims to bridge this gap by conducting a comprehensive literature review of cerebral MRI findings in UE. We hypothesize that specific MRI patterns correlate with the severity and clinical manifestations of UE, thereby enhancing diagnostic accuracy and improving patient outcomes. Methods: A literature review was performed using PubMed, Cochrane Library, and Google Scholar. The search terms included "uremic encephalopathy MRI", "uremia and kidney failure MRI", and "toxic and metabolic or acquired encephalopathies MRI". The inclusion criteria were original articles on UE and MRI findings published in English. Results: Common MRI sequences include T1-weighted, T2-weighted, FLAIR, and DWI. Frequent MRI findings in UE are cytotoxic and vasogenic brain edema in regions such as the basal ganglia and periventricular white matter. Patterns like the "lentiform fork sign" and basal ganglia involvement are key indicators of UE. Conclusions: MRI plays a crucial role in diagnosing UE by identifying characteristic brain edema and specific patterns. A comprehensive diagnostic approach, incorporating clinical, laboratory, and imaging data, is essential for accurate diagnosis and management. The study calls for larger well-designed cohorts with long-term follow-up to improve the understanding and treatment of UE.
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Affiliation(s)
- Federico Greco
- Department of Radiology, Cittadella della Salute, Azienda Sanitaria Locale di Lecce, Piazza Filippo Bottazzi, 2, 73100 Lecce, Italy
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
| | - Andrea Buoso
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Laura Cea
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Valerio D’Andrea
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Caterina Bernetti
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Bruno Beomonte Zobel
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Carlo Augusto Mallio
- Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; (A.B.); (L.C.); (V.D.); (C.B.); (C.A.M.)
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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Hammann N, Lenz D, Bianzano A, Husain RA, Forman E, Bernstein JA, Dattner T, Engelen M, Hanson-Kahn AK, Isidor B, Kotzaeridou U, Tietze A, Trollmann R, Weiß C, Wolffenbuttel BHR, Kölker S, Hoffmann GF, Crushell E, Staufner C, Mohr A, Harting I. MRI in LARS1 deficiency-Spectrum, patterns, and correlation with acute neurological deterioration. J Inherit Metab Dis 2024. [PMID: 38951950 DOI: 10.1002/jimd.12764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 07/03/2024]
Abstract
Leucine aminoacyl tRNA-synthetase 1 (LARS1)-deficiency (infantile liver failure syndrome type 1 (ILFS1)) has a multisystemic phenotype including fever-associated acute liver failure (ALF), chronic neurologic abnormalities, and encephalopathic episodes. In order to better characterize encephalopathic episodes and MRI changes, 35 cranial MRIs from 13 individuals with LARS1 deficiency were systematically assessed and neurological phenotype was analyzed. All individuals had developmental delay and 10/13 had seizures. Encephalopathic episodes in 8/13 were typically associated with infections, presented with seizures and reduced consciousness, mostly accompanied by hepatic dysfunction, and recovery in 17/19 episodes. Encephalopathy without hepatic dysfunction occurred in one individual after liver transplantation. On MRI, 5/7 individuals with MRI during acute encephalopathy had deep gray matter and brainstem changes. Supratentorial cortex involvement (6/13) and cerebellar watershed injury (4/13) occurred with seizures and/or encephalopathy. Abnormal brainstem contour on sagittal images (8/13), atrophy (8/13), and myelination delay (8/13) were not clearly associated with encephalopathy. The pattern of deep gray matter and brainstem changes are apparently characteristic of encephalopathy in LARS1-deficiency, differing from patterns of hepatic encephalopathy or metabolic stroke in organic acidurias and mitochondrial diseases. While the pathomechanism remains unclear, fever and energy deficit during infections might be causative; thus, sufficient glucose and protein intake along with pro-active fever management is suggested. As severe episodes were observed during influenza infections, we strongly recommend seasonal vaccination.
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Affiliation(s)
- Nicole Hammann
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Dominic Lenz
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Alyssa Bianzano
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Ralf A Husain
- Centre for Inborn Metabolic Disorders, Department of Neuropediatrics, Jena University Hospital, Jena, Germany
| | - Eva Forman
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland at Temple Street and Crumlin, Dublin, Ireland
| | - Jonathan A Bernstein
- Department of Pediatrics, Stanford School of Medicine, Stanford, California, USA
- Center for Undiagnosed Diseases, Stanford University, Stanford, California, USA
| | - Tal Dattner
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Marc Engelen
- Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam UMC Location, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Andrea K Hanson-Kahn
- Department of Genetics, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Pediatrics, Division of Medical Genetics, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Bertrand Isidor
- CHU Nantes, Service de Génétique Médicale, Nantes, France
- INSERM, CNRS, UNIV Nantes, l'institut du thorax, Nantes, France
| | - Urania Kotzaeridou
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Anna Tietze
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Regina Trollmann
- Department of Neuropaediatrics, University Hospital Erlangen, Erlangen, Germany
| | - Claudia Weiß
- Department of Neuropediatrics, Sozialpädiatrisches Zentrum (SPZ), Center for Chronically Sick Children, Charité-Universitätsmedizin, Berlin, Germany
- Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan Kölker
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Georg F Hoffmann
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland at Temple Street and Crumlin, Dublin, Ireland
| | - Christian Staufner
- Medical Faculty, University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Alexander Mohr
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Inga Harting
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Yang Y, Zhao H. Diffusion-weighted imaging in methanol poisoning: beyond the lentiform fork sign. Clin Toxicol (Phila) 2024; 62:61-63. [PMID: 38231203 DOI: 10.1080/15563650.2024.2302452] [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] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Methanol poisoning is a life-threatening emergency, in which the presence of a lentiform fork sign on magnetic resonance imaging, although not exclusive to methanol poisoning, can be of diagnostic assistance. This report highlights the additional value of diffusion-weighted imaging in methanol poisoning. CASE SUMMARY A 38-year-old man was admitted to the hospital with severe metabolic acidosis, coma and visual disturbances due to methanol poisoning. IMAGES Initial computed tomography of the brain was unremarkable. However, magnetic resonance imaging revealed the lentiform fork sign, with diffusion-weighted imaging changes in the lentiform nuclei. CONCLUSION Diffusion-weighted imaging sequences provide additional information compared to traditional magnetic resonance imaging in assessing methanol poisoning. Systematic evaluation is needed to fully understand and utilize the potential predictive value of diffusion-weighted imaging in this context.
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Affiliation(s)
- Yan Yang
- Department of Radiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing City, China
| | - Hongwei Zhao
- Department of Radiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing City, China
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Alhusseini A, Hamsho S, Alabdullah H, Alaswad M, Sleiay M, Alsamarrai O. Uremic encephalopathy manifesting with a unique MRI finding (the lentiform fork sign) in an adult male: A case report. Clin Case Rep 2023; 11:e8233. [PMID: 38028094 PMCID: PMC10661331 DOI: 10.1002/ccr3.8233] [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: 10/24/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023] Open
Abstract
A novel radiologic sign in patients with renal failure and uremic encephalopathy (UE) with metabolic acidosis has recently been identified as the lentiform fork sign. On magnetic resonance imaging (MRI), the "lentiform fork sign" has been described as bilateral symmetrical hyperintensities in the basal ganglia encircled by a hyperintese rim delineating the lentiform nucleus. Changes in uremic solute retention, aberrant blood-brain barrier transport, disordered vascular reactivity, altered electrolyte and acid-base balance, and altered hormone metabolism are the most likely causes of the condition. A 56-year-old male with end-stage renal disease was brought to the emergency room for a progressive change in mental status and involuntary arm movements over the previous 5 days, which were accompanied by mild dyspnea. A brain MRI was performed, and it revealed hyperintensity on T2/FLAIR in the white matter surrounding the basal ganglia. the patient was treated with dialysis and improved greatly. Intensified hemodialysis and glycemic control are the cornerstones of treating diabetic uremic syndrome (DUS) with likely reversible clinical symptoms and remission of imaging abnormalities.
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Affiliation(s)
- Ayham Alhusseini
- Neurology Department, Faculty of MedicineDamascus UniversityDamascusSyria
| | - Suaad Hamsho
- Rheumatology Department, Faculty of medicineDamascus UniversityDamascusSyria
| | | | | | | | - Omar Alsamarrai
- Neurology Department, Faculty of MedicineDamascus UniversityDamascusSyria
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Li H, Chen W. Unintended findings: Therapeutic effects of hormones or gamma globulins on Lentiform Fork sign in 3 diabetic uremic patients: Case report/case series. Medicine (Baltimore) 2023; 102:e34819. [PMID: 37653752 PMCID: PMC10470673 DOI: 10.1097/md.0000000000034819] [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: 05/15/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION The lentiform fork sign (LFS) is a unique magnetic resonance imaging (MRI) finding characterized by a bright hyperintense rim delineating the lentiform nucleus as a fork associated with metabolic acidosis in end-stage renal disease. PATIENT CONCERNS We report 3 cases of LFS in diabetic uremic patients. In one case of uremia, intensive hemodialysis treatment was not effective. Given our poor understanding of LFS, it was regarded as bilateral basal ganglia pathology, and pulse hormone and gamma globulins therapy was initiated. The patient neurological symptoms improved, and the pathological signs on imaging subsided. Based on our experience with the first LFS case, 2 diabetic uremic cases presenting with LFS were successfully treated with hormone or gamma globulin pulse therapy in addition to intensive hemodialysis. DIAGNOSIS Based on the clinical manifestations, past medical history and MRI imaging changes of the 3 cases reported here, the diagnosis of LFS was established. INTERVENTIONS Our experience from these 3 cases suggests that hormone supplementation and gamma globulin therapy may be indicated for treating LFS. LESSONS Our findings highlight that in diabetic uremic dialysis patients with neurological symptoms, LFS should be suspected. The clinical manifestations, past medical history and MRI imaging findings are essential for diagnosing LFS. Hormone supplementation and gamma globulin therapy may be the effective treatment for LFS.
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Affiliation(s)
- Hui Li
- Department of Nephrology, Shenzhen Baoxing Hospital, Shenzhen, China
| | - Wenbiao Chen
- Central laboratory, People’s Hospital of Longhua, The Affiliated Hospital of Southern Medical University, Shenzhen, China
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Muralidharan S, Mathew GG, Varadharajan J, Sailapathy S, Natarajan S. Lentiform fork sign in continuous ambulatory peritoneal dialysis. QJM 2023; 116:586-587. [PMID: 37052533 DOI: 10.1093/qjmed/hcad067] [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: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/14/2023] Open
Affiliation(s)
- S Muralidharan
- Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu 603203, Tamil Nadu, India
| | - G G Mathew
- Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu 603203, Tamil Nadu, India
| | - J Varadharajan
- Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu 603203, Tamil Nadu, India
| | - S Sailapathy
- Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu 603203, Tamil Nadu, India
| | - S Natarajan
- Department of Radiology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu 603203, Tamil Nadu, India
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Clingan MJ, Zhang Z, Caserta MP, Cox KL, Gupta V, Baumgarten DA, Zhai QJ, Alexander LF. Imaging Patients with Kidney Failure. Radiographics 2023; 43:e220116. [PMID: 37053100 DOI: 10.1148/rg.220116] [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: 04/14/2023]
Abstract
The approach to imaging a patient with kidney failure continues to evolve. Overstatement of the risk of iodinated contrast material-induced (ie, contrast-induced) acute kidney injury and new guidelines for administration of gadolinium-based contrast media affect screening and the choice of contrast material. Treatment of kidney failure requires dialysis or a kidney transplant. Pretransplant imaging includes assessment for the feasibility of performing a transplant and evaluation for underlying malignancy and peripheral vascular disease. Patients with kidney failure are at high risk for renal cell carcinoma. Subtypes that occur exclusively or more commonly in patients with kidney failure, such as acquired cystic kidney disease, renal cell carcinoma, and clear cell papillary renal cell carcinoma, have specific clinical-pathologic characteristics, with indolent behavior. Performing US for dialysis planning increases the success of placement of an arteriovenous fistula, while postoperative US evaluation is essential in assessment of access dysfunction. Systemic manifestations in patients with kidney failure are multifactorial and may relate to the underlying cause of renal failure or may be secondary to treatment effects. Disturbances in mineral and bone metabolism and soft-tissue and vascular calcifications are seen in patients with chronic kidney disease and mineral bone disorder. Neurologic and cardiothoracic complications are also common. The authors provide a comprehensive overview of imaging considerations for patients with kidney failure, including the appropriate use of CT, MRI, and US with their respective contrast agents; the use of imaging in transplant workup and dialysis assessment; and the common renal and extrarenal manifestations of kidney failure. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Mary Jennings Clingan
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Zhao Zhang
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Melanie P Caserta
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Kelly L Cox
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Vivek Gupta
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Deborah A Baumgarten
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Qihui Jim Zhai
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
| | - Lauren F Alexander
- From the Departments of Radiology (M.J.C., Z.Z., M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville FL 32224
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Hiesgen J, Badenhorst J. Lentiform Fork Sign on Magnetic Resonance Imaging After Methamphetamine and Alcohol Misuse. JAMA Neurol 2023:2803246. [PMID: 37067795 DOI: 10.1001/jamaneurol.2023.0723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
This case report describes a patient with a 3-day history of acute blindness after using alcohol and methamphetamine for 3 consecutive nights before onset of visual impairment.
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Affiliation(s)
- Juliane Hiesgen
- Department of Neurology, University of Pretoria, Pretoria, South Africa
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Sequeira M, Gama Lobo G, Ferro M, Brum M. Lentiform fork sign in uraemic striatopallidal syndrome. Pract Neurol 2023; 23:168-169. [PMID: 36572530 DOI: 10.1136/pn-2022-003610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Marta Sequeira
- Neurology Department, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Gonçalo Gama Lobo
- Neuroradiology Department, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Margarida Ferro
- Neurology Department, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Marisa Brum
- Neurology Department, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
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Sakurai T, Nishida H. Extrapyramidal syndromes of chronic kidney disease and dialysis (diabetic uremic syndrome) with reversible parkinsonism and lentiform fork sign: A case report and literature review including metformin-induced encephalopathy. Heliyon 2023; 9:e14255. [PMID: 36923829 PMCID: PMC10009720 DOI: 10.1016/j.heliyon.2023.e14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/05/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Diabetic uremic syndrome has been rarely reported in patients on maintenance dialysis for diabetic nephropathy who present subacutely with neurological symptoms and bilateral basal ganglia lesions. There are also a few reports on metformin-induced encephalopathy, which is clinically similar to diabetic uremic syndrome. Because some patients with each of these diseases also have metabolic acidosis, it is speculated that these two diseases may have the same pathology. Recently, the term "extrapyramidal syndromes of chronic kidney disease and dialysis" (EPS-CKDD), with associated diagnostic criteria, has been proposed to describe these conditions, and metformin use is considered a risk factor for developing these syndromes. We report a case of a patient on maintenance hemodialysis for diabetic nephropathy who was taking metformin and developed subacute parkinsonism and bilateral basal ganglia lesions that rapidly improved after discontinuation of metformin with continued maintenance hemodialysis. We should ascertain whether patients with EPS-CKDD are taking metformin because it may be inappropriately prescribed for end-stage renal disease. If metformin has been prescribed, it should be discontinued immediately; its discontinuation may lead to rapid symptom recovery and improved prognosis.
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Affiliation(s)
- Takeo Sakurai
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
| | - Hiroshi Nishida
- Department of Neurology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
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12
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Imaging of metabolic and overload disorders in tissues and organs. Jpn J Radiol 2023; 41:571-595. [PMID: 36680702 DOI: 10.1007/s11604-022-01379-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/24/2022] [Indexed: 01/22/2023]
Abstract
Metabolic and overload disorders are a heterogeneous group of relatively uncommon but important diseases. While imaging plays a key role in the early detection and accurate diagnosis in specific organs with a pivotal role in several metabolic pathways, most of these diseases affect different tissues as part of a systemic syndromes. Moreover, since the symptoms are often vague and phenotypes similar, imaging alterations can present as incidental findings, which must be recognized and interpreted in the light of further biochemical and histological investigations. Among imaging modalities, MRI allows, thanks to its multiparametric properties, to obtain numerous information on tissue composition, but many metabolic and accumulation alterations require a multimodal evaluation, possibly using advanced imaging techniques and sequences, not only for the detection but also for accurate characterization and quantification. The purpose of this review is to describe the different alterations resulting from metabolic and overload pathologies in organs and tissues throughout the body, with particular reference to imaging findings.
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13
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Chawla T, Sehgal J, Goyal V. The "Collar Tab Sign"-An Atypical MRI Feature in Uremic Encephalopathy. J Clin Neurol 2023; 19:99-100. [PMID: 36606654 PMCID: PMC9833884 DOI: 10.3988/jcn.2023.19.1.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/09/2022] [Accepted: 10/17/2022] [Indexed: 01/04/2023] Open
Affiliation(s)
- Tanushree Chawla
- DM Neurology, Institute of Neurosciences Medanta, The Medicity Gurugram, Gurugram, India
| | - Jyoti Sehgal
- DNB Neurology, Institute of Neurosciences Medanta, The Medicity Gurugram, Gurugram, India
| | - Vinay Goyal
- DM Neurology, Institute of Neurosciences Medanta, The Medicity Gurugram, Gurugram, India
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14
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Sina F, Najafi D, Aziz-Ahari A, Shahraki E, Ahimahalle TZ, Namjoo Z, Hassanzadeh S. Uremic encephalopathy: A definite diagnosis by magnetic resonance imaging? Eur J Transl Myol 2022; 32. [PMID: 36036353 PMCID: PMC9580542 DOI: 10.4081/ejtm.2022.10613] [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: 05/09/2022] [Accepted: 06/18/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate the magnetic resonance imaging (MRI) findings for the diagnose uremic encephalopathy and describe the usefulness of MRI findings in the ultimate diagnosis of uremic encephalopathy (UE). A total of 20 patients with uremic encephalopathy admitted to the hospital were evaluated in this prospective study. The clinical manifestations, laboratory and MRI imaging findings, demographic information, and clinical outcome were analyzed for each patient. We observed that the 20 prospectively reviewed patients with UE had no involvement of the basal ganglia or the lentiform fork sign (LFS). However, two-thirds of the patients had white matter involvement, and 80% of the subjects had cerebral or cortical atrophy. The arterial blood gas (ABG) analysis revealed that 50% of the patients suffered from metabolic acidosis (n=10). The results of the present study demonstrated that although the observation of Lentiform Fork Sign and Basal Ganglia involvement in MRI of UE patients is a specific finding the absence of which does not rule out UE. Thus, simultaneous examination of clinical manifestation and laboratory test analyses, along with imaging findings, should also be taken into account.
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15
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Manickavasagar R, Chemmanam T, Youssef A, Agarwal A, Prentice DA, Irish AB. The extrapyramidal syndromes of chronic kidney disease and dialysis (EPS-CKDD): diagnostic criteria, risk factors and prognosis. QJM 2022; 115:359-366. [PMID: 34010386 DOI: 10.1093/qjmed/hcab140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/04/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acute extrapyramidal movement disorders in dialysis patients are rare, inconsistently defined and have uncertain aetiology and prognosis. AIM Define diagnostic criteria, prognosis and risk factors. DESIGN AND METHODS Retrospective case series review of 20 patients (14 female, mean age 62 years) receiving dialysis for a median of 15 (interquartile range 4-35) months who presented with acute parkinsonism (AP = 11) or chorea/athetosis (CA = 9). RESULTS All patients had type 2 diabetes (HbA1c 6.8 ± 1.0) and had received metformin. Lactic acidosis was present in 2 patients at presentation and serum lactate was elevated in 7/15 patients tested. No patient had abnormal copper or thyroid metabolism and 5/8 patients tested returned marginal abnormalities in heavy metal screening. Magnetic resonance imaging (MRI) revealed characteristic bilateral symmetric T2 hyperintensity of the basal ganglia (BG), predominantly putamen and globus pallidus (the lentiform nucleus) and more extensive involvement of the external and internal capsules in patients with AP presentation. Post-mortem demonstrated cytotoxic necrosis of the BG. Therapy included thiamine, intensive dialysis and cessation of metformin. Two patients died acutely, nine recovered and nine had residual symptoms. Median survival did not differ by presentation: AP 24 [95% confidence interval (CI) 21-27] and CA 33 (95% CI 32-35) months, P = 0.21. CONCLUSIONS There are two distinct clinical extrapyramidal movement disorders associated with specific diagnostic MRI imaging that support the diagnosis of the extrapyramidal syndromes of chronic kidney disease and dialysis. The associations with diabetes, metformin and metabolic acidosis suggest a common pathogenic mechanism but require additional study. Early recognition and treatment may improve outcomes.
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Affiliation(s)
- R Manickavasagar
- Department of Nephrology and Transplantation, Fiona Stanley Hospital, 11-15 Robin Warren Drive, Murdoch, WA 6150, Australia
| | - T Chemmanam
- Department of Neurology, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, Perth, WA 6009, Australia
| | - A Youssef
- Neurological Intervention and Imaging Service, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - A Agarwal
- Neurological Intervention and Imaging Service, Sir Charles Gairdner Hospital, Hospital Avenue Nedlands, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - D A Prentice
- Perron Institute for Neurological and Translational Science, 8 Verdun St, Nedlands, Perth, WA 6009, Australia
| | - A B Irish
- Department of Nephrology and Transplantation, Fiona Stanley Hospital, 11-15 Robin Warren Drive, Murdoch, WA 6150, Australia
- Faculty of Medicine and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA 6009, Australia
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16
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Geboers K, Vanden Bossche S, Dekeyzer S. Lentiform fork sign in a girl with uremic encephalopathy. Acta Neurol Belg 2022; 122:535-536. [PMID: 34342870 DOI: 10.1007/s13760-021-01764-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- K Geboers
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - S Vanden Bossche
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - S Dekeyzer
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium.
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17
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Hanazono A, Takahashi Y, Sanpei Y, Kamada S, Sugawara M. Focal brain lactate accumulation in metformin-induced encephalopathy without systemic lactic acidosis: A case report suggesting mitochondrial vulnerability in lentiform fork sign. eNeurologicalSci 2021; 25:100383. [PMID: 34917782 PMCID: PMC8645906 DOI: 10.1016/j.ensci.2021.100383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 01/27/2023] Open
Abstract
Metformin causes metabolic encephalopathy in some patients with end-stage chronic kidney disease, resulting in impaired consciousness and parkinsonism. This encephalopathy has a very characteristic magnetic resonance imaging feature in lentiform nuclei known as the “lentiform fork sign”. However, the mechanism is unknown. Here, we report a case of metformin-induced encephalopathy with a novel observation of lactate accumulation in the lentiform nuclei on magnetic resonance spectroscopy without systemic lactic acidosis. Since metformin is an inhibitor of mitochondrial complex-I, this focal brain lactate accumulation implies that a part of the pathogenesis of metformin-induced encephalopathy is the focal vulnerability of mitochondria to metformin in the lentiform nuclei. When metformin causes encephalopathy, not only testing for serum lactic acidosis and performing routine magnetic resonance imaging but also evaluation of brain lactate accumulation by magnetic resonance spectroscopy should be required to elucidate the etiology. Metformin-induced encephalopathy with lactate accumulation in lentiform fork sign was reported. Lentiform nuclei might be more vulnerable to metformin than other organs. This case suggested an etiology for the lentiform fork sign because metformin is a mitochondrial inhibitor.
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Affiliation(s)
- Akira Hanazono
- Akita University Graduate School of Medicine, Department of Neurology, 1-1-1 Hondo, Akita 010-8543, Japan
| | - Yoshiko Takahashi
- Akita University Graduate School of Medicine, Department of Neurology, 1-1-1 Hondo, Akita 010-8543, Japan
| | - Yui Sanpei
- Akita University Graduate School of Medicine, Department of Neurology, 1-1-1 Hondo, Akita 010-8543, Japan
| | - Sachiko Kamada
- Akita University Graduate School of Medicine, Department of Neurology, 1-1-1 Hondo, Akita 010-8543, Japan
| | - Masashiro Sugawara
- Akita University Graduate School of Medicine, Department of Neurology, 1-1-1 Hondo, Akita 010-8543, Japan
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18
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2021; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/20/2022] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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19
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Abstract
Uremic encephalopathy encompasses a wide range of central nervous system abnormalities associated with poor kidney function occurring with either progressive chronic kidney disease or acute kidney injury. The syndrome is likely caused by retention of uremic solutes, alterations in hormonal metabolism, changes in electrolyte and acid-base homeostasis, as well as changes in vascular reactivity, blood-brain barrier transport, and inflammation. There are no defining clinical, laboratory, or imaging findings, and the diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation. The diagnosis is also made difficult because of the many confounding and overlapping conditions seen in patients with chronic kidney disease and acute kidney injury. Thus, institution of kidney replacement therapy should be considered as a trial to improve symptoms in the right clinical context. Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations. Further knowledge linking possible uremic retention solutes with neurological symptoms is needed to better understand this syndrome as well as to develop more tailored treatments that aim to improve cognitive function.
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20
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Narra RK. Lentiform fork sign in uraemic encephalopathy. BMJ Case Rep 2021; 14:e245623. [PMID: 34535496 PMCID: PMC8451301 DOI: 10.1136/bcr-2021-245623] [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: 08/31/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rama Krishna Narra
- Radiodiagnosis, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India
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21
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Radhakrishnan RC, Uthup S, Rajesh L, Pulinilkunnathil RG. Lentiform Fork Sign in a Child on Hemodialysis. Indian J Nephrol 2021; 31:329-330. [PMID: 34376958 PMCID: PMC8330653 DOI: 10.4103/ijn.ijn_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/25/2020] [Accepted: 07/17/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Susan Uthup
- Department of Pediatric Nephrology, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Liji Rajesh
- Department of Pediatric Nephrology, Government Medical College, Thiruvananthapuram, Kerala, India
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22
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Chang YA, Tarng DC, Yang CY. Lentiform fork sign in a uremic patient after inadvertent exposure to metformin. Clin Toxicol (Phila) 2021; 60:406-407. [PMID: 34256673 DOI: 10.1080/15563650.2021.1953519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This case report describes a 56-year-old woman receiving regular hemodialysis for three years who presented with an unsteady gait for one month, dysarthria, and frequent choking on liquids for two weeks. Brain MRI revealed a characteristic "lentiform fork sign" with hyperintense T2W/FLAIR signal in the bilateral lentiform nuclei and restricted diffusion in bilateral globus pallidus. She was inadvertently prescribed metformin 1,000 mg per day one month ago by a physician who was unaware of her end-stage kidney disease. After intensive hemodialysis therapy with eight hemodialysis sessions within 12 days, her neurological deficits fully resolved. Clinicians should be aware of metformin-induced encephalopathy, presenting with relevant medication history, neurological symptoms, and the lentiform fork sign.
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Affiliation(s)
- Yen-An Chang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Chih-Yu Yang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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23
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Laespada-García MI, Azcárate-Díaz FJ, Méndez-Guerrero A. 'Lentiform fork sign' as a radiological feature of posterior reversible encephalopathy syndrome. Acta Neurol Belg 2021; 121:757-759. [PMID: 33721259 DOI: 10.1007/s13760-021-01643-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
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24
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Mansoor S, De Klerk L, Lineen J, Fahad M, Ali I, Coffey B, Mulry MA, Saadat S, Kelly S, Adenan MH, Murphy K. Lentiform fork sign in a uremic patient with a high anion gap metabolic acidosis with seizures: a case report from North West of Ireland. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00234-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Lentiform fork sign is a neuroradiological abnormality which is encountered in the clinical practice associated with uremic encephalopathy, dialysis disequilibrium syndrome and metabolic acidosis.
Case presentation
We describe here a case of this neuro-radiological abnormality which was encountered in a patient with uraemia and high anion gap metabolic acidosis who presented with generalised convulsion and later had some tremor in her hands. In our patient, there were few predisposing factors which might have possibly resulted in this abnormality chronic kidney disease, diabetes mellitus, and metabolic acidosis.
Conclusion
The Lentiform fork sign is a rare occurrence which can be related to a long list of toxic and metabolic causes but in conjunction with metabolic acidosis in chronic kidney disease patients, it can narrow down this list of alternate diagnosis.
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25
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Adolescent with behavioural changes: Diagnostic clues? J Paediatr Child Health 2020; 56:1650-1651. [PMID: 33099832 DOI: 10.1111/jpc.2_15037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 06/01/2020] [Indexed: 11/29/2022]
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26
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Kumar N, Kumar D. Lentiform Fork Sign in Metabolic Acidosis. Ann Neurol 2020; 89:188-189. [PMID: 32893882 DOI: 10.1002/ana.25896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Niraj Kumar
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, India.,Department of Neurology, All India Institute of Medical Sciences, Rishikesh, India
| | - Deepak Kumar
- Department of Radiology, Indira Gandhi Institute of Medical Sciences, Patna, India
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27
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2020; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/01/2023] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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28
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Bhowmick SS, Lang AE. Movement Disorders and Renal Diseases. Mov Disord Clin Pract 2020; 7:763-779. [PMID: 33043074 DOI: 10.1002/mdc3.13005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
Movement disorders often emerge from the interplay of complex pathophysiological processes involving the kidneys and the nervous system. Tremor, myoclonus, ataxia, chorea, and parkinsonism can occur in the context of renal dysfunction (azotemia and electrolyte abnormalities) or they can be part of complications of its management (dialysis and renal transplantation). On the other hand, myoglobinuria from rhabdomyolysis in status dystonicus and certain drugs used in the management of movement disorders can cause nephrotoxicity. Distinct from these well-recognized associations, it is important to appreciate that there are several inherited and acquired disorders in which movement abnormalities do not occur as a consequence of renal dysfunction or vice versa but are manifestations of common pathophysiological processes affecting the nervous system and the kidneys. These disorders are the emphasis of this review. Increasing awareness of these conditions among neurologists may help them to identify renal involvement earlier, take timely intervention by anticipating complications and focus on therapies targeting common mechanisms in addition to symptomatic management of movement disorders. Recognition of renal impairment in a patient with complex neurological presentation may narrow down the differentials and aid in reaching a definite diagnosis.
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Affiliation(s)
- Suvorit S Bhowmick
- Division of Neurology, Department of Medicine, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital University Health Network Toronto Ontario Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital University Health Network Toronto Ontario Canada
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29
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Van Cauter S, Severino M, Ammendola R, Van Berkel B, Vavro H, van den Hauwe L, Rumboldt Z. Bilateral lesions of the basal ganglia and thalami (central grey matter)-pictorial review. Neuroradiology 2020; 62:1565-1605. [PMID: 32761278 PMCID: PMC7405775 DOI: 10.1007/s00234-020-02511-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
The basal ganglia and thalami are paired deep grey matter structures with extensive metabolic activity that renders them susceptible to injury by various diseases. Most pathological processes lead to bilateral lesions, which may be symmetric or asymmetric, frequently showing characteristic patterns on imaging studies. In this comprehensive pictorial review, the most common and/or typical genetic, acquired metabolic/toxic, infectious, inflammatory, vascular and neoplastic pathologies affecting the central grey matter are subdivided according to the preferential location of the lesions: in the basal ganglia, in the thalami or both. The characteristic imaging findings are described with emphasis on the differential diagnosis and clinical context.
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Affiliation(s)
- Sofie Van Cauter
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium. .,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium.
| | - Mariasavina Severino
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Rosamaria Ammendola
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Brecht Van Berkel
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium
| | - Hrvoje Vavro
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, Croatia
| | - Luc van den Hauwe
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.,Department of Medical Imaging, AZ KLINA, Augustijnslei 100, 2930, Brasschaat, Belgium
| | - Zoran Rumboldt
- Department of Radiology, University of Rijeka School of Medicine, Ulica Braće Branchetta 20, 51000, Rijeka, Croatia.,Department of Radiology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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Koksel Y, McKinney A. Potentially Reversible and Recognizable Acute Encephalopathic Syndromes: Disease Categorization and MRI Appearances. AJNR Am J Neuroradiol 2020; 41:1328-1338. [PMID: 32616580 PMCID: PMC7658879 DOI: 10.3174/ajnr.a6634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/26/2020] [Indexed: 01/21/2023]
Abstract
"Encephalopathy" is a vague term that encompasses varying definitions, often with a nonspecific clinical presentation and numerous possible pathophysiologic causes. Hence, MR imaging plays a crucial role in the early diagnosis and treatment by identifying imaging patterns when there is limited clinical history in such patients with acute encephalopathy. The aim of this review was to aid in remembrance of etiologies of potentially reversible acute encephalopathic syndromes on MR imaging. The differential includes vascular (reversible cerebral vasoconstriction syndrome, transient global amnesia, disseminated intravascular coagulation, and thrombotic microangiopathy), infection (meningitis, encephalitis), toxic (posterior reversible encephalopathy syndrome, acute toxic leukoencephalopathy; carbon monoxide, alcohol-related, medication- and illicit drug-related toxic encephalopathies), autoimmune, metabolic (osmotic demyelination syndrome, uremic, acute hepatic encephalopathy), idiopathic/inflammatory (stroke-like migraine attacks after radiation therapy syndrome), neoplasm-related encephalopathy, and seizure-related encephalopathy.
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Affiliation(s)
- Y. Koksel
- From the Department of Radiology (Y.K.), Division of Neuroradiology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - A.M. McKinney
- Department of Radiology (A.M.M.), University of Miami School of Medicine, Miami, Florida
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31
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Berrada M, Benkirane N, El Moutawakil B, Rafai MA, El Otmani H. An MRI pattern of metformin-associated encephalopathy in hemodialysis. Rev Neurol (Paris) 2020; 177:312-313. [PMID: 32631674 DOI: 10.1016/j.neurol.2020.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/18/2022]
Affiliation(s)
- M Berrada
- Department of neurology, Ibn-Rochd Hospital, University college of Medicine Hassan-II, Casablanca, Morocco.
| | - N Benkirane
- Department of neurology, Ibn-Rochd Hospital, University college of Medicine Hassan-II, Casablanca, Morocco
| | - B El Moutawakil
- Department of neurology, Ibn-Rochd Hospital, University college of Medicine Hassan-II, Casablanca, Morocco; Laboratoire de génétique et pathologie moléculaire, University college of Medicine Hassan-II, Casablanca, Morocco
| | - M A Rafai
- Department of neurology, Ibn-Rochd Hospital, University college of Medicine Hassan-II, Casablanca, Morocco
| | - H El Otmani
- Department of neurology, Ibn-Rochd Hospital, University college of Medicine Hassan-II, Casablanca, Morocco; Laboratoire de génétique et pathologie moléculaire, University college of Medicine Hassan-II, Casablanca, Morocco
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32
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Sotoudeh H, Chapman PR, Sotoudeh E, Singhal A, Choudhary G, Shafaat O. Pseudohypoxic Brain Swelling: Report of 2 Cases and Introduction of the Lentiform Rim Sign as Potential MRI Marker. World Neurosurg 2020; 133:221-226. [DOI: 10.1016/j.wneu.2019.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 11/16/2022]
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33
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Jaryal A, Thakur S, Pathania JS, Vikrant S, Kumar D, Verma L. Lentiform fork sign: Uremia alone or multifactorial causation? Hemodial Int 2019; 24:E10-E12. [PMID: 31840926 DOI: 10.1111/hdi.12810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 11/28/2022]
Abstract
Neurological complications are common in patients with acute or chronic renal failure, especially when there is marked reduction in the glomerular filtration rate (GFR). One such clinical syndrome, uremic encephalopathy (UE), occurs due to widespread dysfunction of central nervous system (CNS). It manifests with myriad clinical features and usually is suggested by bedside elicitation of asterixis (flapping tremor). Symptomatic involvement of the basal ganglia manifesting as choreoathetosis and clinical and radiological resolution with hemodialysis has been reported in the medical literature, but only rarely. The present report details such a case.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Suresh Thakur
- Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, India
| | | | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Dinesh Kumar
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
| | - Lokesh Verma
- Department of Medicine, Indira Gandhi Medical College, Shimla, India
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34
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de Oliveira AM, Paulino MV, Vieira APF, McKinney AM, da Rocha AJ, dos Santos GT, Leite CDC, Godoy LFDS, Lucato LT. Imaging Patterns of Toxic and Metabolic Brain Disorders. Radiographics 2019; 39:1672-1695. [DOI: 10.1148/rg.2019190016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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35
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Abstract
Metformin-associated encephalopathy in maintenance hemodialysis is very rare in literature, till now only three to four cases are published. We report a patient on maintenance hemodialysis from standalone unit presented to us with abnormal neurological signs and symptoms. His medication chart included metformin, which he was taking for quite a long time. Computed tomography brain showed hypointensity in bilateral basal ganglia. Magnetic resonance imaging (MRI) brain showed hyperintensity in T2/fluid-attenuated inversion recovery sequences suggestive of Lentiform fork sign. We stopped metformin, and he was continued on regular hemodialysis. He showed dramatic improvement in neurological manifestations. Two months later, we repeated MRI brain, which showed resolution of basal ganglia changes. We should suspect the possibility of this when a diabetic end-stage renal disease presents with unknown etiology of encephalopathy.
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Affiliation(s)
- S P Simon
- Department of Nephrology, Rajagiri Hospital, Kochi, Kerala, India
| | - J Thomas
- Department of Nephrology, Rajagiri Hospital, Kochi, Kerala, India
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36
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McGarvey C, Franconi C, Prentice D, Bynevelt M. Metformin-induced encephalopathy: the role of thiamine. Intern Med J 2018; 48:194-197. [PMID: 29415360 DOI: 10.1111/imj.13693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 03/19/2017] [Indexed: 11/30/2022]
Abstract
A case of metformin encephalopathy is presented in a patient on haemodialysis for end-stage diabetic renal failure. The patient presented with frequent falls and clinical signs of Parkinsonism, on a background of recent anorexia and significant weight loss. Magnetic resonance imaging showed bilateral, symmetrical abnormalities centred on the lentiform nuclei. Metformin was withheld and signs and symptoms quickly resolved. We hypothesise that metformin may cause thiamine deficiency in patients with end-stage renal failure resulting in a specific metabolic encephalopathy.
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Affiliation(s)
- Caoimhe McGarvey
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Catherine Franconi
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David Prentice
- Department of General Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Michael Bynevelt
- Department of Neurological Intervention and Imaging Service of WA, Royal Perth Hospital, Perth, Western Australia, Australia
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37
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Saini AG, Kodakkattil Sreevilasan S, Singh P, Singhi P. Lentiform fork sign due to severe metabolic acidosis. BMJ Case Rep 2017; 2017:bcr-2017-222871. [PMID: 29212873 DOI: 10.1136/bcr-2017-222871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Arushi Gahlot Saini
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Paramjeet Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Singhi
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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38
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Das N, Wu X, Malhotra A. Regarding "Uremic Encephalopathy: MR Imaging Findings and Clinical Correlation". AJNR Am J Neuroradiol 2017; 38:E23-E24. [PMID: 28082265 DOI: 10.3174/ajnr.a5058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- N Das
- Department of Radiology and Biomedical Imaging Yale School of Medicine
| | | | - A Malhotra
- Department of Radiology and Biomedical Imaging Yale School of Medicine New Haven, Connecticut
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39
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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40
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Teaching neuroimages: 'Blind drunk': neuroimaging findings in methanol poisoning. Acta Neurol Belg 2016; 116:637-638. [PMID: 26811094 DOI: 10.1007/s13760-015-0594-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
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41
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Kim DM, Lee IH, Song CJ. Uremic Encephalopathy: MR Imaging Findings and Clinical Correlation. AJNR Am J Neuroradiol 2016; 37:1604-9. [PMID: 27127003 DOI: 10.3174/ajnr.a4776] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/12/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Uremic encephalopathy is a metabolic disorder in patients with renal failure. The purpose of this study was to describe the MR imaging findings of uremic encephalopathy. MATERIALS AND METHODS This study retrospectively reviewed MR imaging findings in 10 patients with clinically proved uremic encephalopathy between May 2005 and December 2014. Parameters evaluated were lesion location and appearance; MR signal intensity of the lesions on T1WI, T2WI, and T2 fluid-attenuated inversion recovery images; the presence or absence of restricted diffusion on diffusion-weighted images and apparent diffusion coefficient maps; and the reversibility of documented signal-intensity abnormalities on follow-up MR imaging. RESULTS MR imaging abnormalities accompanying marked elevation of serum creatinine (range, 4.3-11.7 mg/dL) were evident in the 10 patients. Nine patients had a history of chronic renal failure with expansile bilateral basal ganglia lesions, and 1 patient with acute renal failure had reversible largely cortical lesions. Two of 6 patients with available arterial blood gas results had metabolic acidosis. All basal ganglia lesions showed expansile high signal intensity (lentiform fork sign) on T2WI. Varied levels of restricted diffusion and a range of signal intensities on DWI were evident and were not correlated with serum Cr levels. All cortical lesions demonstrated high signal intensity on T2WI. Four patients with follow-up MR imaging after hemodialysis showed complete resolution of all lesions. CONCLUSIONS The lentiform fork sign is reliable in the early diagnosis of uremic encephalopathy, regardless of the presence of metabolic acidosis. Cytotoxic edema and/or vasogenic edema on DWI/ADC maps may be associated with uremic encephalopathy.
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Affiliation(s)
- D M Kim
- From the Department of Radiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - I H Lee
- From the Department of Radiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.
| | - C J Song
- From the Department of Radiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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42
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Ahuja CK, Yadav MK, Khandelwal N. Mystery Case: Syndrome of bilateral basal ganglia lesions in uremic encephalopathy. Neurology 2016; 86:e182-3. [PMID: 27164646 DOI: 10.1212/wnl.0000000000002602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Chirag Kamal Ahuja
- From the Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Mukesh Kumar Yadav
- From the Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Niranjan Khandelwal
- From the Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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43
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Park JW, Kim SU, Choi JY, Jung JM, Kwon DY, Park MH. Reversible parkinsonism with lentiform fork sign as an initial and dominant manifestation of uremic encephalopathy. J Neurol Sci 2015; 357:343-4. [DOI: 10.1016/j.jns.2015.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
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44
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Derle E, Kibaroglu S, Cınar P, Öcal R, Can U. Lentiform fork sign in a case with end-stage renal disease and metabolic acidosis. Acta Neurol Belg 2015; 115:411-3. [PMID: 25381213 DOI: 10.1007/s13760-014-0388-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 10/28/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Eda Derle
- Department of Neurology, School of Medicine, Baskent University, Mareşal Fevzi Çakmak Cad. 10. sok No: 45, Bahçelievler, Ankara, Turkey,
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Kaiwar C, Fernandes GC, Rieder CR, Vedolin L, Campos L, Koltermann T. Teaching NeuroImages: The lentiform fork sign: An MRI pattern of metformin-associated encephalopathyAuthor Response. Neurology 2015; 85:655. [DOI: 10.1212/wnl.0000000000001847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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46
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Grasso D, Borreggine C, Perfetto F, Bertozzi V, Trivisano M, Specchio LM, Grilli G, Macarini L. Lentiform fork sign: a magnetic resonance finding in a case of acute metabolic acidosis. Neuroradiol J 2014; 27:288-92. [PMID: 24976195 DOI: 10.15274/nrj-2014-10041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/05/2014] [Indexed: 11/12/2022] Open
Abstract
We report a 33 year-old woman addicted to chronic unspecified solvents abuse with stupor, respiratory disorders, tetraplegia and severe metabolic acidosis. On admission an unenhanced cranial CT scan showed symmetrical hypodensities of both lentiform nuclei. MR imaging performed 12 hours after stupor demonstrates bilateral putaminal hemorrhagic necrosis, bilateral external capsule, corona radiata and deep cerebellar hyperintensities with right cingulate cortex involvement. DWI reflected bilateral putaminal hyperintensities with restricted water diffusion as to citotoxic edema and development of vasogenic edema in the external capsule recalling a fork. On day twenty, after specific treatments MRI demonstrated a bilateral putaminal marginal enhancement. Bilateral putaminal necrosis is a characteristic but non-specific radiological finding of methanol poisoning. Lentiform Fork sign is a rare MRI finding reported in literature in 22 patients with various conditions characterized by metabolic acidosis. Vasogenic edema may be due to the differences in metabolic vulnerability between neurons and astrocytes. We postulate that metabolic acidosis could have an important role to generate this sign.
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Affiliation(s)
- Daniela Grasso
- Department of Imaging Diagnostics, University of Foggia; Foggia, Italy -
| | - Carmela Borreggine
- Specialisation School in Radiodiagnostics, University of Foggia; Foggia, Italy
| | - Francesco Perfetto
- Radiodiagnostic Unit, "Ospedali Riuniti" University Hospital; Foggia, Italy
| | - Vincenzo Bertozzi
- Radiodiagnostic Unit, "Ospedali Riuniti" University Hospital; Foggia, Italy
| | - Marina Trivisano
- Specialisation School in Neurology, University of Foggia; Foggia, Italy
| | | | - Gianpaolo Grilli
- Radiodiagnostic Unit, "Ospedali Riuniti" University Hospital; Foggia, Italy
| | - Luca Macarini
- Specialisation School in Radiodiagnostics, University of Foggia; Foggia, Italy
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47
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Neurologic complications of acute and chronic renal disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:383-93. [PMID: 24365307 DOI: 10.1016/b978-0-7020-4086-3.00024-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
There is an increasing incidence and prevalence of patients with chronic kidney disease (CKD) in Western industrialized countries and currently is estimated at approximately 10% of adults aged over 20 years. Renal failure causes an excessively increased risk of cerebrovascular and cardiovascular complications. Moreover, renal failure leads to a number of the neurologic symptoms neurologists are often confronted with. This chapter gives an overview of possible neurologic complications of acute renal failure and CKD. Complications of the central nervous system (e.g., uremic encephalopathy, disequilibrium syndrome, and drug induced disorders) are reviewed. It has long been known that uremia leads to peripheral nerve injury. Frequent neurological diseases such as uremic polyneuropathy, autonomic neuropathy, and a range of mononeuropathies are discussed.
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48
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Lentiform fork sign and fluctuating, reversible parkinsonism in a patient with uremic encephalopathy. Mov Disord 2013; 28:1053. [DOI: 10.1002/mds.25503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 02/27/2013] [Accepted: 04/09/2013] [Indexed: 11/07/2022] Open
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49
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da Rocha AJ, Maia AC, da Silva CJ, Sachetti SB. Lentiform fork sign in a child with dialysis disequilibrium syndrome: A transient MRI pattern which emphasizes neurologic consequence of metabolic acidosis. Clin Neurol Neurosurg 2013; 115:790-2. [DOI: 10.1016/j.clineuro.2012.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 07/08/2012] [Accepted: 07/09/2012] [Indexed: 10/28/2022]
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50
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Baizabal-Carvallo JF, Stocco A, Muscal E, Jankovic J. The spectrum of movement disorders in children with anti-NMDA receptor encephalitis. Mov Disord 2013; 28:543-7. [DOI: 10.1002/mds.25354] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/22/2012] [Accepted: 12/09/2012] [Indexed: 11/07/2022] Open
Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic; Department of Neurology; Baylor College of Medicine; Houston; Texas; USA
| | - Amber Stocco
- Division of Pediatric Neurology and Developmental Neuroscience; Texas Children's Hospital; Baylor College of Medicine; Houston; Texas; USA
| | | | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic; Department of Neurology; Baylor College of Medicine; Houston; Texas; USA
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