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Jansen N, Wulff L, Conty M, Schäbitz WR, Klingebiel R. CHANTER syndrome in the context of pain medication: a case report. BMC Neurol 2024; 24:249. [PMID: 39039495 PMCID: PMC11265104 DOI: 10.1186/s12883-024-03748-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 07/02/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND CHANTER (Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion) is a recently described syndrome occurring in the context of drug abuse. While clinical findings are rather unspecific (disorientation, unresponsiveness), MR imaging (MRI) discloses a characteristic pattern (restricted diffusion in the basal ganglia and hippocampi, cerebellar oedema and haemorrhage), allowing for timely diagnosis before complications such as cerebellar swelling and herniation do occur. Here we report a case of CHANTER primarily based on imaging findings, as there was no evidence of drug abuse on admission. CASE PRESENTATION A 62-year-old Patient was admitted to our hospital after being unresponsive at home. Prehospital intubation was performed, which limited neurological assessment. Under these circumstances no obvious symptoms could be determined, i.e. pupils were isocoric and responsive, and there were no signs of seizures. While the initial CT scan was unremarkable, the subsequent MRI scan showed a distinct imaging pattern: moderately enhancing areas in the basal ganglia and hippocampi with diffusion restriction, accompanied by cerebellar haemorrhage and oedema (Figs. 1 and 2). A comprehensive clinical and laboratory work-up was performed, including drug screening, spinal tap, Holter ECG, echocardiography and EEG. The only conspicuous anamnestic finding was a chronic pain syndrome whose medication had been supplemented with opioids two months previously. The opioid medication was discontinued, which led to a rapid improvement in the patient's clinical condition without any further measures. The patient was able to leave the intensive care unit and was discharged 10 days after admission without persistent neurological deficits. CONCLUSION Familiarity with typical MRI patterns of toxic encephalopathy in patients from high-risk groups, such as drug abusers, is crucial in emergency neuroradiology. In the presence of typical MRI findings, CHANTER syndrome should be included in the differential diagnosis, even if there is no history of drug abuse, to avoid delay in diagnosis and treatment.
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Affiliation(s)
- Nils Jansen
- Department of Neuroradiology, Ev. Klinikum Bethel, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany.
| | - Leonard Wulff
- Department of Neurology, Ev. Klinikum Bethel, University Hospital OWL, Campus Bielefeld- Bethel, Bielefeld, Germany
| | - Moritz Conty
- Department of Neuroradiology, Ev. Klinikum Bethel, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Ev. Klinikum Bethel, University Hospital OWL, Campus Bielefeld- Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Department of Neuroradiology, Ev. Klinikum Bethel, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
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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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Chau LQ, Crawford JR. Neuroimaging features of accidental fentanyl overdose in a toddler. BMJ Case Rep 2024; 17:e258524. [PMID: 38191218 PMCID: PMC10806892 DOI: 10.1136/bcr-2023-258524] [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] [Indexed: 01/10/2024] Open
Abstract
The opioid epidemic has become a significant public health crisis worldwide. With the rise in popularity of fentanyl, opioid overdoses continue to rise at unprecedented rates. Unfortunately, young children have become collateral damage in the face of the opioid epidemic. Accidental exposures and ingestions are the leading cause of opioid overdose in this age group and can result in significant acute complications, long-term sequelae and even death. We present the case of a toddler with accidental fentanyl ingestion who experienced seizures and required intubation for respiratory distress. He was found to have notable diffusion restriction cerebellar changes on MRI and ultimately discharged with normal neurological function. Our case adds to the growing literature of the clinical presentation and neuroimaging features associated with opioid toxicity in young children.
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Affiliation(s)
- Lianne Q Chau
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - John Ross Crawford
- Pediatrics, University of California Irvine, Irvine, California, USA
- Pediatrics, Children's Hospital Orange County, Orange, California, USA
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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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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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