Central pontine myelinolysis - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Introduction Central pontine myelinolysis is a non-inflammatory, usually symmetrical demyelination of the central basis pontis. The exact mechanism is yet to be found. Any way it occurs when the prolonged and severe hyponatraemia is corrected rapidly. In around 10% of patients with central pontine demyelination there would be other regions of the brain as well, especially mid brain, thalamus, basal nuclei, and cerebellum. Several theories are proposed. Most theories suggest the pathology due to the effect of osmosis. The cellular edema may occur due to the fluctuating osmotic forces which leads compression on fibres tracts and resulting demyelination. The oedema occurs when the prolonged or severer hyponatraemia is corrected rapidly with sodium.During the time of hyponatraemia in patient the intracellular charged protein moieties are altered, but the rapid correction with sodium will not correct in a parallel manner. Therefore those intracellular electrolyte imbalance also contributes to the myelinolysis. The localization of the pathology to the pons and other extra-pontine areas will be due to the nature of compact gray and white matter.There are several risk factors and conditions making it is more susceptible which are discussed latter. Patients following liver transplant is vulnerable. The condition is usually irreversible and can be fatal. Improvement may take weeks and months. Patients who recovered also will have persistent disability. The disease doesn't have a gender preference. Introduction
Central pontine myelinolysis is a non-inflammatory, usually symmetrical demyelination of the central basis pontis. The exact mechanism is yet to be found. Any way it occurs when the prolonged and severe hyponatraemia is corrected rapidly. In around 10% of patients with central pontine demyelination there would be other regions of the brain as well, especially mid brain, thalamus, basal nuclei, and cerebellum. Several theories are proposed. Most theories suggest the pathology due to the effect of osmosis. The cellular edema may occur due to the fluctuating osmotic forces which leads compression on fibres tracts and resulting demyelination. The oedema occurs when the prolonged or severer hyponatraemia is corrected rapidly with sodium.During the time of hyponatraemia in patient the intracellular charged protein moieties are altered, but the rapid correction with sodium will not correct in a parallel manner. Therefore those intracellular electrolyte imbalance also contributes to the myelinolysis. The localization of the pathology to the pons and other extra-pontine areas will be due to the nature of compact gray and white matter.There are several risk factors and conditions making it is more susceptible which are discussed latter. Patients following liver transplant is vulnerable. The condition is usually irreversible and can be fatal. Improvement may take weeks and months. Patients who recovered also will have persistent disability. The disease doesn't have a gender preference.
History of hyponatraemia The patient or family members may know about the history of hyponatraemia or will give a history of vomiting, loose stool, consumption of drugs or infection causing hyponatraemia. Patient has usually recovered from the delirium and confusion with IV fluids and sodium replacement. So for around 48 hours following the recovery the patient may assymptomatic functioning well. Patient may start to deteriorate following that period of well being. Those symptoms are as follows. History of hyponatraemia
The patient or family members may know about the history of hyponatraemia or will give a history of vomiting, loose stool, consumption of drugs or infection causing hyponatraemia. Patient has usually recovered from the delirium and confusion with IV fluids and sodium replacement. So for around 48 hours following the recovery the patient may assymptomatic functioning well. Patient may start to deteriorate following that period of well being. Those symptoms are as follows.
Confusion Due to the evolving pathology as mentioned above patient may be confused. It could be due to the cerebral edema. Delirium and coma also can be present due to lesions in potine tegmentum or thalamus. Confusion
Due to the evolving pathology as mentioned above patient may be confused. It could be due to the cerebral edema. Delirium and coma also can be present due to lesions in potine tegmentum or thalamus.
Diplopia on lateral vision or inability to look lateral. Due to the involvement of pons there would be a lateral gaze palsy. Lesions in mid brain may cause verticle gaze palsy. Diplopia on lateral vision or inability to look lateral.
Due to the involvement of pons there would be a lateral gaze palsy. Lesions in mid brain may cause verticle gaze palsy.
Inability to move limbs The patient will have features of spastic quadriplegia which are further discussed later. Inability to move limbs
The patient will have features of spastic quadriplegia which are further discussed later.
Head and neck weakness Due to the pseudobulbar palsy the head and neck weakness is present. Head and neck weakness
Due to the pseudobulbar palsy the head and neck weakness is present.
Dysphagia or dysarthria Again due to the pseudobulbar palsy the dysphagia or dysarthria can be present. Dysphagia or dysarthria
Again due to the pseudobulbar palsy the dysphagia or dysarthria can be present.
Locked-in-syndrome The spastic quadriplegia, pseudobulbar palsy causing head and neck muscle weakness with dysphagia and dysarthria or even mutism may cause locked-in-syndrome in where the patient is unresponsive and immobile. But in locked in syndrome usually the blinking, vertical eye movements, breathing and alertness is intact. Locked-in-syndrome
The spastic quadriplegia, pseudobulbar palsy causing head and neck muscle weakness with dysphagia and dysarthria or even mutism may cause locked-in-syndrome in where the patient is unresponsive and immobile. But in locked in syndrome usually the blinking, vertical eye movements, breathing and alertness is intact.
Comatose states Due to the involvement of pontine tegmentum, reticular activating system or thalumus the patient may be in coma, the patient is unconsciousness and unable to be awakened. Comatose states
Due to the involvement of pontine tegmentum, reticular activating system or thalumus the patient may be in coma, the patient is unconsciousness and unable to be awakened.
Features of aspiration pneumonia Due to the immobility, swallowing difficulty, impaired reflexes there is a high chance of having orthostatic and aspiration pneumonia. Those could be fever, breathing difficulty, phlegm production. Features of aspiration pneumonia
Due to the immobility, swallowing difficulty, impaired reflexes there is a high chance of having orthostatic and aspiration pneumonia. Those could be fever, breathing difficulty, phlegm production.
Features of deep vein thrombosis and pulmonary embolism Due to the immobility patients are in risk to have deep vein thrombosis and pulmonary embolism. Features are calf pain, fever, leg swelling, shortness of breath and chest pain. Features of deep vein thrombosis and pulmonary embolism
Due to the immobility patients are in risk to have deep vein thrombosis and pulmonary embolism. Features are calf pain, fever, leg swelling, shortness of breath and chest pain.
Bed sores Patients are bed bound and more prone to get pressure ulcers. Bed sores
Patients are bed bound and more prone to get pressure ulcers.
Contractures Due to the long term disuse of muscles there may be contactures. Contractures
Due to the long term disuse of muscles there may be contactures.
Disability following recovery Even though some patients may recover over weeks and months they might develop disability in later. These could be behavioral or intellectual impairment or movement disorders like parkinsonism especially if extra pontine. Disability following recovery
Even though some patients may recover over weeks and months they might develop disability in later. These could be behavioral or intellectual impairment or movement disorders like parkinsonism especially if extra pontine.
Hyponatraemia As mentioned previously hyponatraemia is the sole predisposing factor for the disease. So such history can be elicited as above. Hyponatraemia
As mentioned previously hyponatraemia is the sole predisposing factor for the disease. So such history can be elicited as above.
Liver transplantation Liver transplantation surgeries can be complicated with central pontine myelinolysis and it is well known. It has to be suspected when confusion and weakness is present during post operative recovery. But the typical funding of myelinolysis may be masked due to concurrent neuropathy and myopathy in these patients. Liver transplantation
Liver transplantation surgeries can be complicated with central pontine myelinolysis and it is well known. It has to be suspected when confusion and weakness is present during post operative recovery. But the typical funding of myelinolysis may be masked due to concurrent neuropathy and myopathy in these patients.
Other predisposing factors Alcoholism, malnutrition, immunodeficiency (HIV/AIDS), severe burns and liver disease also known to predispose central pontine myelinolysis. Other predisposing factors
Alcoholism, malnutrition, immunodeficiency (HIV/AIDS), severe burns and liver disease also known to predispose central pontine myelinolysis.

Clinicals - Examination

Fact Explanation
Level of consciousness The patient may be confused with disorientation in time, place and person. There may be memory impairment and disability in recalling. Delirium may be present and some patients may be comatose with out being aroused or unresponsive to deep stimuli. Level of consciousness
The patient may be confused with disorientation in time, place and person. There may be memory impairment and disability in recalling. Delirium may be present and some patients may be comatose with out being aroused or unresponsive to deep stimuli.
Gaze paralysis with the involvement of pons there may be a horizontal gaze paralysis and rarely there would be a vertical gaze paralysis with involvement of mid brain. Therefore the vertical eye movement is usually spared. Gaze paralysis
with the involvement of pons there may be a horizontal gaze paralysis and rarely there would be a vertical gaze paralysis with involvement of mid brain. Therefore the vertical eye movement is usually spared.
Motor examination of limbs Typically there would be a spastic quadriplegia. The deep tendon reflexes are exaggerated and Babinski's sign is positive due to the involvement of upper tracts. Motor examination of limbs
Typically there would be a spastic quadriplegia. The deep tendon reflexes are exaggerated and Babinski's sign is positive due to the involvement of upper tracts.
Cranial nerves and head and neck examination with the pseudobulbar palsy 9th, 10th, 11th, 12th cranial nerves are paralysed and patient will have dysarthria and dysphagia. It also causes weakness of head and neck muscles. when these symptoms are combined with the severe quadriplegia the patient is aware about the exterior but unable respond to the exterior. This status is called as "locked in syndrome". Cranial nerves and head and neck examination
with the pseudobulbar palsy 9th, 10th, 11th, 12th cranial nerves are paralysed and patient will have dysarthria and dysphagia. It also causes weakness of head and neck muscles. when these symptoms are combined with the severe quadriplegia the patient is aware about the exterior but unable respond to the exterior. This status is called as "locked in syndrome".
Severely disturbed conscious level or state of unresponsiveness As mentioned previously the patient may be comatose or may be in "locked in syndrome". Glasgow coma scale has to be assessed. There by the patient would be immobile and bed bound leading multiple complications including follows and pressure ulcers. Severely disturbed conscious level or state of unresponsiveness
As mentioned previously the patient may be comatose or may be in "locked in syndrome". Glasgow coma scale has to be assessed. There by the patient would be immobile and bed bound leading multiple complications including follows and pressure ulcers.
Features of aspiration pneumonia Patient may be in respiratory distress and will be febrile. Auscultation and respiratory tract examination may reveal the evidence of consolidation. Features of aspiration pneumonia
Patient may be in respiratory distress and will be febrile. Auscultation and respiratory tract examination may reveal the evidence of consolidation.
Evidence of deep vein thrombosis and pulmonary embolism The patient due to the prolonged bed bound status may develop DVT with tender swollen calves which may be associated with low grade fever. Patient may be restless, dyspnoeic, tachycardic and hypotensive when complicated with pulmonary embolism. Evidence of deep vein thrombosis and pulmonary embolism
The patient due to the prolonged bed bound status may develop DVT with tender swollen calves which may be associated with low grade fever. Patient may be restless, dyspnoeic, tachycardic and hypotensive when complicated with pulmonary embolism.
Evidence of joint contractures Due to the prolonged disuse of the skeletal muscles there would be fixed or dynamic contractures involving large and small joints. Evidence of joint contractures
Due to the prolonged disuse of the skeletal muscles there would be fixed or dynamic contractures involving large and small joints.
Long term complications As a long term complication patient may develop intellectual disability and parkinsonism features. Tremor, stooped gait, rigidity, hypokinesia has to be checked in these patients. Long term complications
As a long term complication patient may develop intellectual disability and parkinsonism features. Tremor, stooped gait, rigidity, hypokinesia has to be checked in these patients.

Investigations - Diagnosis

Fact Explanation
Imaging with MRI scan of the brain and brain stem MRI is the method of imaging to detect central pontine myelinolysis. Initial imaging may not show a change and a series of MRI may be needed. It should be T2 weighted imaging and will show areas of demyelination. Imaging with MRI scan of the brain and brain stem
MRI is the method of imaging to detect central pontine myelinolysis. Initial imaging may not show a change and a series of MRI may be needed. It should be T2 weighted imaging and will show areas of demyelination.
Electroencephalography (EEG) EEG will show typical diffuse bihemispheric slowing. Electroencephalography (EEG)
EEG will show typical diffuse bihemispheric slowing.
Brainstem-evoked potentials This is used when the imaging is unsuccessful in concluding a the diagnosis. Brainstem-evoked potentials
This is used when the imaging is unsuccessful in concluding a the diagnosis.
Series of serum sodium If these sodium values are available it will give the most important clue regarding the previous hyponatraemia which has been corrected rapidly. Series of serum sodium
If these sodium values are available it will give the most important clue regarding the previous hyponatraemia which has been corrected rapidly.
CSF analysis CSF analysis is not essential and can be carried out in doubtful situations. But it is usually normal. That will demonstrate elevated protein, increased opening pressure or mononuclear pleocytosis. CSF analysis
CSF analysis is not essential and can be carried out in doubtful situations. But it is usually normal. That will demonstrate elevated protein, increased opening pressure or mononuclear pleocytosis.

Investigations - Management

Fact Explanation
Serum electrolytes As mentioned above for the diagnosis as well as for the management available series of serum sodium is far important. It will show the previous degree of hyponatraemia and rate of its correction. This will guide the further electrolyte management. Serum electrolytes
As mentioned above for the diagnosis as well as for the management available series of serum sodium is far important. It will show the previous degree of hyponatraemia and rate of its correction. This will guide the further electrolyte management.
Basic investigations with full blood count and other renal function tests including creatine This will give the patients base line status and will be needed to repeat during the disease course. Increased wBC may denote the infection and renal funtion has to be assessed regularly. Basic investigations with full blood count and other renal function tests including creatine
This will give the patients base line status and will be needed to repeat during the disease course. Increased wBC may denote the infection and renal funtion has to be assessed regularly.
Liver function tests including serum protein levels Malnutrition, alcoholism and liver diseases may predispose the central pontine myelinolysis and have to be identified. If present vitamin supplementation is needed. Liver function tests including serum protein levels
Malnutrition, alcoholism and liver diseases may predispose the central pontine myelinolysis and have to be identified. If present vitamin supplementation is needed.
Inflammatory markers such as CRP, ESR These will denote the occurrence of complicating infections such as aspiration pneumonia, infected bed sore and urinary tract infection. Inflammatory markers such as CRP, ESR
These will denote the occurrence of complicating infections such as aspiration pneumonia, infected bed sore and urinary tract infection.
Chest X ray Is needed when the respiratory signs are present to diagnose and assess the aspiration pneumonoa. Chest X ray
Is needed when the respiratory signs are present to diagnose and assess the aspiration pneumonoa.
D-dimer and lower limb venous duplex when the DVT or pulmonary embolism is suspected these investigations has to be carried out. D-dimer and lower limb venous duplex
when the DVT or pulmonary embolism is suspected these investigations has to be carried out.
ECG, CT pulmonary angiogram (CTPA) These are needed when the pulmonary embolism is suspected. ECG, CT pulmonary angiogram (CTPA)
These are needed when the pulmonary embolism is suspected.

Management - Supportive

Fact Explanation
Prevention The prevention of the central pontine myelinolysis is far important as the established condition is having poor prognosis with risk of death. Meticulous correction of hyponatraemia is the sole method to prevent it via preventing rapid correction of hyponatraemia. Prevention
The prevention of the central pontine myelinolysis is far important as the established condition is having poor prognosis with risk of death. Meticulous correction of hyponatraemia is the sole method to prevent it via preventing rapid correction of hyponatraemia.
Health education Patient and specially the family members should be informed regarding the natural course of the illness and the poor prognosis. Family members should be educated about the lack of active interventions and available supportive care. Health education
Patient and specially the family members should be informed regarding the natural course of the illness and the poor prognosis. Family members should be educated about the lack of active interventions and available supportive care.
Prevention of bed sores when the patients are bed bound they are more prone to have pressure ulcers. Timely turning, using an air mattress, timely wound dressing may prevent the extensive bed sores. Prevention of bed sores
when the patients are bed bound they are more prone to have pressure ulcers. Timely turning, using an air mattress, timely wound dressing may prevent the extensive bed sores.
Nutrition when the patients are having dysphagia naso gastric feeding is indicated. Malnutrition also aggravates the condition and nutritional supplementation may be necessary. Nutrition
when the patients are having dysphagia naso gastric feeding is indicated. Malnutrition also aggravates the condition and nutritional supplementation may be necessary.
Bladder and bowel care when the patient is having incontinence patient has to be catheterized. Bowel care should be continued to maintain a good hygiene in bed bound patient. Bladder and bowel care
when the patient is having incontinence patient has to be catheterized. Bowel care should be continued to maintain a good hygiene in bed bound patient.
Chest physiotherapy and feeding in propped up position These measures will minimize the risk of having aspiration pneumonia. Chest physiotherapy and feeding in propped up position
These measures will minimize the risk of having aspiration pneumonia.
Prevention of deep vein thrombosis Better hydration, physiotherapy, class I stocking and prophylactic anti coagulation may prevent the occurrence of DVT and pulmonary embolism. Physiotherapy also prevents the occurrence of joint contractures. Prevention of deep vein thrombosis
Better hydration, physiotherapy, class I stocking and prophylactic anti coagulation may prevent the occurrence of DVT and pulmonary embolism. Physiotherapy also prevents the occurrence of joint contractures.
Neurorehabilitation Patient may have permanent cognitive and intellectual even following recovery. Some may have parkinsonism. These patients has to be properly rehabilitated. Drug management for the parkinsonism may be needed. Neurorehabilitation
Patient may have permanent cognitive and intellectual even following recovery. Some may have parkinsonism. These patients has to be properly rehabilitated. Drug management for the parkinsonism may be needed.

Management - Specific

Fact Explanation
Supportive management only, no specific management. As mentioned previously there is no specific management for central pontine myelinolysis other than the prevention and the supportive care. Any specific reason for the electrolyte imbalance has to be found and treated promptly if present. Supportive management only, no specific management.
As mentioned previously there is no specific management for central pontine myelinolysis other than the prevention and the supportive care. Any specific reason for the electrolyte imbalance has to be found and treated promptly if present.

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