Extrapontine myelinolysis presenting as acute parkinsonism

Extra-pontine Myelinolysis After Rapid Correction of Hyponatremia Responding to Levodopa

Osmotic demyelinating disease of the central nervous system has two variants: central pontine myelinolysis and extra-pontine myelinolysis (EPM). Up to 10% of cases of osmotic demyelination syndrome are associated with EPM, which mostly affects the thalamus and basal ganglia. It is commonly associated with the rapid correction of hyponatremia. An elderly woman in her 60s presented with complaints of acute gastroenteritis and giddiness and visited the emergency ward. On examination, she was conscious and oriented to time but disoriented to place and person and had slurring of speech with signs of dehydration. Her serum sodium levels were 100 meq/L, and her brain MRI was normal. After shifting her to the intensive care unit, she was treated with 200 ml of 3% NaCl bolus to correct her hyponatremia. On day three, she began developing rigidity in both lower limbs, which progressed to the upper limbs with hyperreflexia and mutism. A brain MRI was done, which showed subtle hyperintensities in the caudate lobe with no other new findings. Her serum aldosterone and cortisol were on the lower side of the normal range. Treatment of tablet levodopa-carbidopa (100/25) combination thrice a day (TDS) led to an improvement in her health condition.

Temporal Brain MRI Changes From Extrapontine Myelinolysis to Central Pontine Myelinolysis: A Case Report

We present a case that was initially misdiagnosed as drug-related extrapyramidal side effect. However, after the suspected causative drugs were withdrawn, the patient’s condition did not improve. Neuroimaging revealed osmotic demyelination syndrome with a temporal pattern of change from extrapontine myelinolysis to central pontine myelinolysis. Given the limited literature on this rare condition, further research to support clinical diagnosis and treatment is needed.

The cascade to a serendipitous discovery of lithium-induced nephrogenic diabetes insipidus

Lithium therapy is a common treatment for affective disorders and is widely regarded as a lifesaving drug. However, because its elimination is almost wholly unchanged via the kidneys, both acute and long-term adverse effects relating to toxicity may occur, including declining renal function and nephrogenic diabetes insipidus (DI). DI may be difficult to detect and is frequently preceded by dehydration and which, in our patient, was discovered by chance. We describe a case of an elderly woman on chronic lithium therapy for bipolar affective disorder who initially presented with dehydration from vomiting but possibly developed extra-pontine myelinolysis (EPM) after over-zealous correction of hyponatraemia. Steroids administered appeared to have prevented further progression but a persisting hyperosmolar state then alerted us to the presence of nephrogenic DI. Although both conditions were later successfully reversed with no obvious chronic sequelae, the recovery of the patient was protracted. Clinicians should be vigilant for complications of managing dehydration states in people prescribed with lithium.

Dramatic Response to Pramipexole in Delayed-Onset Parkinsonism from Osmotic Demyelinating Syndrome

Background:

Delayed parkinsonism and dystonia are recognized phenomena in osmotic demyelinating syndrome (ODS). Dopamine receptor agonists and levodopa have been reported to benefit select patients.

Case report:

We report a patient with ODS with severe pseudobulbar deficits, parkinsonism and dystonia, poorly responsive to levodopa, who experienced a remarkable improvement with pramipexole.

Discussion:

A marked response to pramipexole with lack of response to levodopa suggests a pre-synaptic source for his deficits coupled with injuries to non-nigral compensatory structures.

Highlights:

This case highlights a dramatic response of osmotic demyelination-induced parkinsonism/dystonia to pramipexole. A lack of response to levodopa suggests deficits in the pre-synaptic nigral as well as non-nigral compensatory structures.

Parkinsonism and neurosarcoidosis: Cause and effect or coincidence?

Movement disorders in demyelinating diseases can be coincidental or secondary to a demyelinating lesion. We here report the first case of coincidental association of neurosarcoidosis and idiopathic Parkinson's disease.

Acute parkinsonism as an unexpected consequence of pituitary adenoma resection: A case report

INTRODUCTION

Transsphenoidal resection of pituitary tumors is a surgery performed through the nose and sphenoid sinus to remove pituitary tumors. Disorders of sodium balance are common after transsphenoidal surgery involving the pituitary gland. Here, we report the clinical features of an original case of acute onset parkinsonism later confirmed to be secondary to transsphenoidal resection of pituitary adenoma.

PATIENT CONCERNS

A 36-year-old female had received transsphenoidal pituitary resection for pituitary adenoma. Eight days after the surgery, she suffered from acute onset general weakness and nausea/vomiting. She was diagnosed with hyponatremia for which she was treated. Acute onset ataxia, bilateral hand tremor, and dysarthria were then noted on the 4th day of hyponatremia treatment.

DIAGNOSIS

Based on history, clinical manifestation, and MRI brain images, a diagnosis of acute parkinsonism caused by isolated extrapontine myelinolysis (EPM) was made.

INTERVENTIONS

Patient was treated with levodopa/carbidopa.

OUTCOMES

Patient's symptoms and signs improved gradually and 2 month follow-up MRI brain showed significant resolution of the bilateral lentiform nuclei hyperintensities on the T2-weighted images. Her neurological deficits had subsided completely.

LESSONS

This case highlights an unexpected association between transsphenoidal resection of pituitary tumors and acute parkinsonism which is a treatable manifestation of EPM. Correction of hyponatremia following transsphenoidal pituitary resections should be preceded cautiously because even gradual correction of hyponatremia can produce myelinolysis.

The Dilemma of Inadvertent Pontine Demyelinosis: A Review of Literature

Osmotic demyelination syndrome is classically associated with a swift adjustment of previously low serum sodium levels which lead to cellular dehydration and subsequent neurological insult. We also review the epidemiology, different postulations to explain the underlying pathophysiology, current diagnostic modalities, subsequent therapeutic interventions used to manage this phenomenon, and the resultant prognosis of this ailment.

Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation?

Hyponatremia is a common electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.

Type 1 diabetes mellitus and isolated adrenocorticotropin deficiency manifested by parkinsonism: a case report and literature review

A 67-year-old woman developed isolated adrenocorticotropin deficiency (IAD), which manifested as lethargy, a 20-kg body weight loss, hypoglycemia, and parkinsonism, and began corticosteroid replacement. Her symptoms resolved rapidly, and her weight returned to normal within six months. However, she then developed slowly progressive type 1 diabetes mellitus (T1D) with co-existing Hashimoto thyroiditis, and commenced insulin therapy. To our knowledge, this is the first reported case of parkinsonism associated with IAD. In addition, because diabetes mellitus, including T1D, could be latent in patients with untreated IAD, careful assessment of glucose metabolism is needed after commencing corticosteroid replacement until weight regain is achieved.

Adrenal disorders and the paediatric brain: pathophysiological considerations and clinical implications

Various neurological and psychiatric manifestations have been recorded in children with adrenal disorders. Based on literature review and on personal case-studies and case-series we focused on the pathophysiological and clinical implications of glucocorticoid-related, mineralcorticoid-related, and catecholamine-related paediatric nervous system involvement. Childhood Cushing syndrome can be associated with long-lasting cognitive deficits and abnormal behaviour, even after resolution of the hypercortisolism. Exposure to excessive replacement of exogenous glucocorticoids in the paediatric age group (e.g., during treatments for adrenal insufficiency) has been reported with neurological and magnetic resonance imaging (MRI) abnormalities (e.g., delayed myelination and brain atrophy) due to potential corticosteroid-related myelin damage in the developing brain and the possible impairment of limbic system ontogenesis. Idiopathic intracranial hypertension (IIH), a disorder of unclear pathophysiology characterised by increased cerebrospinal fluid (CSF) pressure, has been described in children with hypercortisolism, adrenal insufficiency, and hyperaldosteronism, reflecting the potential underlying involvement of the adrenal-brain axis in the regulation of CSF pressure homeostasis. Arterial hypertension caused by paediatric adenomas or tumours of the adrenal cortex or medulla has been associated with various hypertension-related neurological manifestations. The development and maturation of the central nervous system (CNS) through childhood is tightly regulated by intrinsic, paracrine, endocrine, and external modulators, and perturbations in any of these factors, including those related to adrenal hormone imbalance, could result in consequences that affect the structure and function of the paediatric brain. Animal experiments and clinical studies demonstrated that the developing (i.e., paediatric) CNS seems to be particularly vulnerable to alterations induced by adrenal disorders and/or supraphysiological doses of corticosteroids. Physicians should be aware of potential neurological manifestations in children with adrenal dysfunction to achieve better prevention and timely diagnosis and treatment of these disorders. Further studies are needed to explore the potential neurological, cognitive, and psychiatric long-term consequences of high doses of prolonged corticosteroid administration in childhood.

Cerebral encephalopathy with extrapontine myelinolysis in a case of postpartum hypernatremia

Extrapontine myelinolysis, a fairly common metabolic disorder, is associated with neurological complications. Central pontine and extrapontine myelinolysis are commonly recognized with rapid correction of sodium. Myelinolysis, however, has rarely been described with hypernatremia. We report a rare case of post-partum hypernatremic encephalopathy associated with serum sodium levels as high as 200 mEq/l on presentation. Although the serum sodium levels were brought down gradually, subsequent imaging showed progression of demyelination and deterioration of the neurological status.

A case of acute onset parkinsonism

Extra pontine myelinolysis (EPM) is a form of osmotic demyelination syndrome, characterized by the presence of signal alterations in varied sites in the brain other than the pons. When caudate and putamen are involved, it results in a constellation of extra pyramidal signs and symptoms resembling parkinsonism. Here we report a case of this unique syndrome presenting with features of parkinsonism which was successfully treated with dopaminergic drugs.

Hemichorea associated with nonketotic hyperglycemia: clinical and neuroimaging features in 12 patients

BACKGROUND

Nonketotic hyperglycemia is a rare cause of hemichorea. Patients with hemichorea associated with nonketotic hyperglycemia (HCNH) always have a favorable prognosis when given prompt treatment.

METHODS

We reviewed the medical records of 12 patients with HCNH in our hospital between January 2005 and January 2013. The clinical data, laboratory findings, and imaging features of the patients were collected.

RESULTS

All 12 patients were admitted to the hospital with a complaint of involuntary movements. Ten patients had a history of diabetes, while the other 2 patients had not been diagnosed. The mean level of blood glucose on admission was 330.7 ± 107.8 mg/dl, and the ketones were negative. A cranial computed tomography scan showed hyperdensity in the striatum, which quickly resolved. Magnetic resonance imaging showed hyperintensity on T1-weighted images without change over several months. Nearly all of the patients experienced relief from the hemichorea symptoms after correcting hyperglycemia with a combination of dopamine receptor inhibitors and the sedative lorazepam, if necessary.

CONCLUSION

HCNH is a benign disorder, the pathogenesis of which remains unclear. Radiologic changes can provide guidance for early treatment and generally give an estimation of the degree of injury.

Central Pontine and Extrapontine Myelinolysis in a Patient with Traumatic Brain Injury Following Not Rapid Correction of Hyponatremia: A Case Report

Central pontine myelinolysis occurs inconsistently as a complication of severe and prolonged hyponatremia, particularly when corrected too rapidly. This condition is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. We describe a head injury patient who developed central pontine and extrapontine myelinolysis following a gradual correction of hyponatremia. More attention should be paid to correcting hyponatremia combined with hypokalemia in patients who have a history of alcoholism.

Movement disorders and the osmotic demyelination syndrome

With the advent of MRI, osmotic demyelination syndromes (ODS) are increasingly recognised to affect varied sites in the brain in addition to the classical central pontine lesion. Striatal involvement is seen in a large proportion of cases and results in a wide variety of movement disorders. Movement disorders and cognitive problems resulting from ODS affecting the basal ganglia may occur early in the course of the illness, or may present as delayed manifestations after the patient survives the acute phase. Such delayed symptoms may evolve over time, and may even progress despite treatment. Improved survival of patients in the last few decades due to better intensive care has led to an increase in the incidence of such delayed manifestations of ODS. While the outcome of ODS is not as dismal as hitherto believed - with the acute akinetic-rigid syndrome associated with striatal myelinolysis often responding to dopaminergic therapy - the delayed symptoms often prove refractory to medical therapy. This article presents a review of the epidemiology, pathophysiology, clinical features, imaging, and therapy of movement disorders associated with involvement of the basal ganglia in ODS. A comprehensive review of 54 previously published cases of movement disorders due to ODS, and a video recording depicting the spectrum of delayed movement disorders seen after recovery from ODS are also presented.

Isolated extrapontine myelinolysis of osmotic demyelination syndrome

The osmotic demyelination syndrome (ODS) has been identified as a complication of the rapid correction of hyponatremia for decades (King and Rosner, 2010). However, in recent years, a variety of other medical conditions have been associated with the development of ODS, independent of changes in serum sodium which cause a rapid changes in osmolality of the interstitial (extracellular) compartment of the brain leading to dehydration of energy-depleted cells with subsequent axonal damage that occurs in characteristic areas (King and Rosner, 2010). Slow correction of the serum sodium concentration and additional administration of corticosteroids seems to be a major prevention step in ODS patients. In the current report we aimed to share a rare case which we observed in our clinic.

Extrapontine myelinolysis-induced parkinsonism in a patient with adrenal crisis

Background. Extrapontine myelinolysis (EPM) has been well described in the presence of rapid correction of hyponatremia. It is seldom reported with adrenal insufficiency. We report a unique case where a patient developed EPM as a result of adrenal insufficiency where the brain MRI revealed symmetrical lesion in the basal ganglia with pallidal sparing. Case Report. A 30-year-old gentleman with panhypopituitarism developed adrenal crisis, hyponatremia, and hyponatremic encephalopathy. Seven days after the rapid correction of hyponatremia, he developed parkinsonism and neuropsychiatric symptoms. MRI showed extrapontine myelinolysis without central pontine myelinolysis. Conclusion. Extrapontine myelinolysis without central pontine myelinolysis is rare and should raise a concern of associated adrenal insufficiency in the right clinical setting. Rapid correction of hyponatremia particularly in steroid-deficient states should be avoided as it can predispose to extrapontine myelinolysis. Magnetic resonance imaging is very helpful in supporting the diagnosis of EPM.

Isolated extra pontine myelinolysis presenting as acute onset parkinsonism

A 50-year-old woman was brought to the emergency department with complaints of altered mental status, her serum sodium at that time was 103 mmol/l. Slow correction of hyponatraemia was started but despite every effort serum sodium rise was rapid. Although the patient improved initially, after 4 days she presented with features of parkinsonism. MRI brain was done and it was suggestive of features of EPM. She responded well to levodopa plus carbidopa therapy.

A prospective series of patients with hyperglycaemia-associated movement disorders

Hyperglycaemia-associated movement disorders (MD) usually appear in older patients with diabetes and are related to acute peaks in blood glucose levels. This study aimed to describe the clinical features of a prospective series of patients with movement disorders associated with hyperglycaemia. We present a series of seven women and three men diagnosed with hyperglycaemia-associated MD who were followed for at least 1 year. Clinical evolution, treatment and neuroimaging findings are presented. Mean (± standard deviation [SD]) of the age at onset was 67.7 ± 11.7 years and mean (± SD) fasting glucose was 359.7 ± 162.5mg/dL. Putaminal hyperintensity on T1-weighted MRI was present in almost all instances. Two patients had pontine lesions compatible with osmotic myelinolysis. At follow-up, eight patients had a complete remission. We conclude that the clinical profile of patients in our series is similar to those reported in the literature. No clinical or metabolic features were found to be correlated with remission. Similarities with osmotic myelinolysis syndromes are discussed as an alternative aetiological hypothesis.

Transient Parkinsonism in isolated extrapontine myelinolysis

Extrapontine myelinolysis (EPM) is a rare cause of Parkinsonism. In this case report, we describe a 63-year-old woman with Parkinsonism due to EPM after correction of hyponatremia. During a 4-year follow-up, both the clinical features of Parkinsonism and the changes on magnetic resonance imaging resolved. Parkinsonism due to EPM should be recognized as it has a good prognosis.