Abstract
Many toxic agents induce brain dysfunction and/or lesions. Modern neuroimaging techniques, such as CT and more recently magnetic resonance imaging (MRI), are able to demonstrate toxic brain lesions at both early and delayed phases of disease progression. In the early phase, neuroimaging enables the detection of acutely injured brain areas responsible for sudden onset of neurological dysfunction, but the severity and the extension of brain lesions on neuroimages do not necessarily parallel the severity of the clinical status. In the chronic phase, when neurological dysfunction has become permanent, neuroimaging allows precise identification of neuroanatomical sequelae that do not necessarily match the severity of the chronic neurological impairment. Papers in the medical imaging literature have dealt mainly with the brain changes induced by ‘chronic exposure’ to toxic substances such as solvents or heavy metals. This article selectively reviews the main radiological changes observed on CT/magnetic resonance (MR) neuroimages after ‘acute exposure’ to industrial products (methanol [methyl alcohol], ethylene glycol), environmental agents (cyanide, carbon monoxide), pharmaceuticals (insulin, valproic acid) and illicit substances (heroin, cocaine). Different kinds of lesions, which lack specificity for toxic injury, can be observed on radiological images, but deep grey matter lesions with symmetrical distribution throughout basal ganglia are most often seen. However, such findings have also been reported after anoxic-ischaemic insults or during severe metabolic disturbances. Lesions in the white matter may also be present in the case of acute exposure to toxic agents. The true prognostic value of toxic-induced brain changes in the acute phase in CT or MR studies is unclear, although serial MRI may add new information as may quantitative or molecular imaging techniques such as the MR diffusion-weighted imaging or MR spectroscopy.
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References
Dietemann JL, Botelho C, Nogueira T, et al. Imaging in acute encephalopathy. J Neuroradiol 2004; 31: 313–26
Lang CJ. The use of neuroimaging techniques for clinical detection of neurotoxicity: a review. Neurotoxicology 2000; 21: 847–56
Singhal AB, Topcuoglu MA, Koroshetz WJ. Diffusion MRI in three types of anoxic encephalopathy. J Neurol Sci 2002; 196: 37–40
Chalela J, Wolf RL, Maldjian JA, et al. MRI identification of early white matter injury in anoxic-ischemic encephalopathy. Neurology 2001; 56: 481–5
Kamei S, Takasu T, Mori N, et al. Serial imaging of bilateral striatal necrosis associated with acidaemia in adults. Neuroradiology 1996; 38: 437–40
Brierly JB, Graham DI. Hypoxia and vascular disorders of the central nervous system. In: Adams JH, Corsellis JAN, Duchen LW, editors. Greenfield’s neuropathology. London: Edward Arnold, 1984: 125–207
Sawada H, Udaka F, Seriu N, et al. MRI demonstration of cortical laminar necrosis and delayed white matter injury in anoxic encephalopathy. Neuroradiology 1990; 32: 319–21
Orthner H. Die methylalkohol Vergiftung. Berlin: Springer Verlag, 1950
McLean DR, Jacobs H, Mielke BW. Methanol poisoning: a clinical and pathological study. Ann Neurol 1980; 8: 161–7
Glazer M, Dross P. Necrosis of the putamen caused by methanol intoxication: MR findings. AJR Am J Roentgenol 1993; 160: 1105–6
Phang PT, Passerini L, Mielke B, et al. Brain hemorrhage associated with methanol poisoning. Crit Care Med 1988 Feb; 16(2): 137–40
Gaul HP, Wallace CJ, Auer RN, et al. MR findings in methanol intoxication. AJNR Am J Neuroradiol 1995; 16: 1783–6
Aquilonius SM, Askmark H, Enoksson P, et al. Computerised tomography in severe methanol intoxication. BMJ 1978; 309: 929–30
Mittal B V, Desai AP, Khade KR. Methyl alcohol poisoning: an autopsy study of 28 cases. J Postgrad Med 1991; 37: 9–13
Feany MB, Anthony DC, Frosch MP, et al. August 2000: two cases with necrosis and hemorrhage in the putamen and white matter. Brain Pathol 2001; 11: 121–5
Fontenot AP, Pelak VS. Development of neurologic symptoms in a 26-year-old woman following recovery from methanol intoxication. Chest 2002; 122: 1436–9
Bitar ZI, Ashebu SD, Ahmed S. Methanol poisoning: diagnosis and management: a case report. Int J Clin Pract 2004; 58: 1042–4
Bourrat C, Riboullard L, Flocard F, et al. Voluntary methanol poisoning: severe regressive encephalopathy with anomalies on x-ray computed tomography. Rev Neurol 1986; 142: 530–4
Pelletier J, Habib MH, Khalil R, et al. Putaminal necrosis after methanol intoxication. J Neurol Neurosurg Psychiatry 1992; 55: 234–5
Bartoli JM, Laurent C, Moulin G, et al. Methanol intoxication: CT and MRI findings — report of two cases. Ann Radiol (Paris) 1990; 33: 257–9
Chen JC, Schneiderman JF, Wortzman G. Methanol poisoning: bilateral putaminal and cerebellar cortical lesions on CT and MR. J Comput Assist Tomogr 1991; 15: 522–4
Kuteifan K, Oesterle H, Tajahmady T, et al. Necrosis and haemorrhage of the putamen in methanol poisoning shown on MRI. Neuroradiology 1998; 40: 158–60
Anderson CA, Rubinstein D, Filley CM, et al. MR enhancing brain lesions in methanol intoxication. J Comput Assist Tomogr 1997; 21: 834–6
Hantson PH, Duprez T, Mahieu P. Neurotoxicity to the basal ganglia shown by brain magnetic resonance imaging (MRI) following poisoning by methanol and other substances. J Toxicol Clin Toxicol 1997; 35: 151–61
Rubinstein D, Escott E, Kelly JP. Methanol intoxication with putaminal and white matter necrosis: MR and CT findings. AJNR Am J Neuroradiol 1995; 16: 1492–4
Hsu HH, Chen CY, Chen FH, et al. Optic atrophy and cerebral infarcts caused by methanol intoxication: MRI. Neuroradiology 1997; 39: 192–4
Deniz S, Oppenheim C, Lehericy S, et al. Diffusion-weighted magnetic resonance imaging in a case of methanol intoxication. Neurotoxicology 2000; 21: 405–8
Server A, Hovda KE, Nakstad PH, et al. Conventional and diffusion-weighted MRI in the evaluation of methanol poisoning. Acta Radiol 2003; 44: 691–5
Halavaara J, Valanne L, Setala K. Neuroimaging supports the clinical diagnosis of methanol poisoning. Neuroradiology 2002; 44: 924–8
Kim JH, Chang KH, Song IC, et al. Delayed encephalopathy of acute carbon monoxide intoxication: diffusivity of cerebral white matter lesions. AJNR Am J Neuroradiol 2003; 24: 1592–7
Zeiss J, Brinker R. Role of contrast enhancement in cerebral CT of carbon monoxide poisoning. J Comput Assist Tomogr 1988; 12: 341–3
Rachinger J, Fellner FA, Stieglbauer K, et al. MR changes after acute cyanide intoxication. AJNR Am J Neuroradiol 2002; 23: 1398–401
Tobé TJ, Braam GB, Meulenbelt J, et al. Ethylene glycol poisoning mimicking Snow White. Lancet 2002; 359: 444–5
Lewis LD, Smith BW, Mamourian AC. Delayed sequelae after acute overdoses or poisonings: cranial neuropathy related to ethylene glycol ingestion. Clin Pharmacol Ther 1997; 61: 692–9
Morgan BW, Ford MD, Follmer R. Ethylene glycol ingestion resulting in brainstem and midbrain dysfunction. J Toxicol Clin Toxicol 2000; 38: 445–51
Steinke W, Arendt G, Mull M, et al. Good recovery after sublethal ethylene glycol intoxication: serial EEG and CT findings. J Neurol 1989; 236: 170–3
Zeiss J, Velasco ME, McCann KM, et al. Cerebral CT of lethal ethylene glycol intoxication with pathologic correlation. AJNR Am J Neuroradiol 1989; 10: 440–2
Chung PK, Tuso P. Cerebral computed tomography in a stage IV ethylene glycol intoxication. Conn Med 1989; 53: 513–4
Bobbitt WH, Williams RM, Freed CR. Severe ethylene glycol intoxication with multisystem failure. West J Med 1986; 144: 225–8
Maier W. Cerebral computed tomography of ethylene glycol intoxication. Neuroradiology 1983; 24: 175–7
Hantson P, Vanbinst R, Mahieu P. Determination of ethylene glycol tissue content after fatal oral poisoning and pathologic findings. Am J Forensic Med Pathol 2002; 23: 159–61
Grandas F, Artieda J, Obeso JA. Clinical and CT scan findings in a case of cyanide intoxication. Mov Disord 1989; 4: 188–93
Valenzuela R, Court J, Godoy J. Delayed cyanide induced dystonia. J Neurol Neurosurg Psychiatry 1992; 55: 198–9
Feldman JM, Feldman MD. Sequelae of attempted suicide by cyanide ingestion: a case report. Int J Psychiatry Med 1990; 20: 173–9
Rosenow F, Herholz K, Lanfermann H, et al. Neurological sequelae of cyanide intoxication: the patterns of clinical, magnetic resonance imaging, and positron emission tomography findings. Ann Neurol 1995; 38: 825–8
Messing B, Storch B. Computer tomography and magnetic resonance imaging in cyanide poisoning. Eur Arch Psychiatry Neurol Sci 1988; 237: 139–43
Rosenberg NL, Myers JA, Martin WR. Cyanide-induced parkinsonism: clinical, MRI, and 6-fluorodopa PET studies. Neurology 1989; 39: 142–4
Messing B. Extrapyramidal disturbances after cyanide poisoning (first MRT-investigation of the brain). J Neural Transm Suppl 1991; 33: 141–7
Borgohain R, Singh AK, Radhakrishna H, et al. Delayed onset generalised dystonia after cyanide poisoning. Clin Neurol Neurosurg 1995; 97: 213–5
Zaknun JJ, Stieglbauer K, Trenkler J, et al. Cyanide-induced akinetic rigid syndrome: clinical, MRI, FDG-PET, beta-CIT and HMPAO SPECT findings. Parkinsonism Relat Disord 2005; 11: 125–9
Kasamo K, Okuhata Y, Satoh R, et al. Chronological changes of MRI findings on striatal damage after acute cyanide intoxication: pathogenesis of the damage and its selectivity, and prevention for neurological sequelae: a case report. Eur Arch Psychiatry Clin Neurosci 1993; 243: 71–4
Riudavets MA, Aronica-Pollak P, Troncoso JC. Pseudolaminar necrosis in cyanide intoxication: a neuropathology case report. Am J Forensic Med Pathol 2005; 26: 189–91
Tuchmann R, Moser F, Moshe S. Carbon monoxide poisoning: bilateral lesions in the thalamus on MR imaging of the brain. Pediatr Radiol 1990; 20: 478–9
Jakular V, Penney D, Crowley M, et al. Magnetic resonance imaging of the rat brain following acute carbon monoxide poisoning. J Appl Toxicol 1992; 12: 407–14
O’Donnell P, Buxton PJ, Pitkin A, et al. The magnetic resonance imaging appearances of the brain in acute carbon monoxide poisoning. Clin Radiol 2000; 55: 273–80
Bianco F, Floris R. MRI appearances consistent with hemorrhagic infarction as an early manifestation of carbon monoxide poisoning. Neuroradiology 1996; 38: s70–2
Ferrier D, Wallace CJ, Fletcher WA, et al. Magnetic resonance features in carbon monoxide poisoning. Can Assoc Radiol J 1994; 45: 466–8
Kawanami T, Kato T, Kurita K, et al. The pallidoreticular pattern of brain damage on MRI in a patient with carbon monoxide poisoning. J Neurol Neurosurg Psychiatry 1998; 64: 282
Parkinson RB, Hopkins RO, Cleavinger HB, et al. White matter hyperintensities and neuropsycchological outcome following carbon monoxide poisoning. Neurology 2002; 58: 1525–32
Finelli PF, DiMario FJ. Hemorrhagic infarction in white matter following acute carbon monoxide poisoning. Neurology 2004; 63: 1102–4
Sener RN. Acute carbon monoxide poisoning: diffuse MR imaging findings. AJNR Am J Neuroradiol 2003; 24: 1475–7
Choi IS, Kim SK, Choi YC, et al. Evaluation of outcome after acute carbon monoxide poisoning by brain CT. J Korean Med Sci 1993; 8: 78–83
Yoshii F, Kozuma R, Takahashi W, et al. Magnetic resonance imaging and 11C-N-methylspiperone/positron emission tomography studies in a patient with the interval form of carbon monoxide poisoning. J Neurol Sci 1998; 160: 87–91
Gotoh M, Kuyama H, Asari S, et al. Sequential changes in MR images of the brain in acute CO poisoning. Comput Med Imaging Graph 1993; 17: 55–9
Choi IS. Delayed neurologic sequelae in carbon monoxide intoxication. Arch Neurol 1983; 40: 433–5
Ginsberg MD, Myers RE, McDonagh BF. Experimental carbon monoxide encephalopathy in the primate II: clinical aspects, neuropathology, and physiologic correlation. Arch Neurol 1974; 30: 209–16
Gandini C, Prockop LD, Butera R, et al. Pallidoreticular-rubral brain damage on magnetic resonance imaging after carbon monoxide poisoning. J Neuroimaging 2002; 12: 102–3
Lapresle J, Fardeau M. The central nervous system and carbon monoxide poisoning. II: anatomical study of brain lesions following intoxication with carbon monoxide. Prog Brain Res 1967; 24: 31–74
Chang KH, Han MH, Kim HS, et al. Delayed encephalopathy after acute CO intoxication: MR imaging features and distribution of cerebral white matter lesions. Radiology 1992; 184: 177–22
Kim HY, Kim BJ, Moon SY, et al. Serial diffusion-weighted MR imaging in delayed postanoxic encephalopathy. J Neuroradiol 2002; 29: 211–5
Murata T, Kimura H, Kado H, et al. Neuronal damage in the interval form of CO poisoning determined by serial diffusion weighted magnetic resonance imaging plus 1H-magnetic resonance spectroscopy. J Neurol Neurosurg Psychiatry 2001; 71: 250–3
Teksam M, Casey SO, Michel E, et al. Diffusion weighted MR imaging findings in carbon monoxide poisoning. Neuroradiology 2002; 44: 109–13
Chu K, Jung KH, Kim HJ, et al. Diffusion-weighted MRI and 99mTc-HMPAO SPECT in delayed relapsing type of carbon monoxide poisoning: evidence of delayed cytotoxic edema. Eur Neurol 2004; 51: 98–103
Murata T, Itoh S, Koshino Y, et al. Serial cerebral MRI with FLAIR sequences in acute carbon monoxide poisoning. J Comput Assist Tomogr 1995; 19: 631–4
Prockop LD. Carbon monoxide brain toxicity: clinical, magnetic resonance imaging, magnetic resonance spectroscopy, and neuropsychological effects in 9 people. J Neuroimaging 2005; 15: 144–9
Fujioka M, Okuchi K, Hiramatsu KI, et al. Specific changes in human brain after hypoglycemie injury. Stroke 1997; 28: 584–7
Jung SL, Kim BS, Lee KS, et al. Magnetic resonance imaging and diffusion-weighted imaging changes after hypoglycemie coma. J Neuroimaging 2005; 15: 193–6
Shirayama H, Oshiro Y, Kinjo Y, et al. Acute brain injury in hypoglycaemia-induced hemiplegia. Diabet Med 2004; 21: 623–4
Maekawa S, Aibiki M, Kikuchi K, et al. Time related changes in reversible MRI findings after prolonged hypoglycemia. Clin Neurol Neurosurg 2005; 108(5): 511–3
Spiller HA, Krenzelok EP, Klein-Schwartz W. Multicenter case series of valproic acid ingestion: serum concentrations and toxicity. Clin Toxicol 2000; 38: 755–60
Poklis A, Poklis JL, Trautman D. Disposition of valproic acid in a case of fatal intoxication. J Anal Toxicol 1998; 22: 537–40
Thabet H, Brahmi N, Amamou M. Hyperlactatemia and hyperammonemia as secondary effects of valproic acid poisoning [letter]. Am J Emerg Med 2000; 18: 508
Sztajnkrycer MD. Valproic acid toxicity: overview and management. J Toxicol Clin Toxicol 2002; 40: 789–801
Baganz MD, Dross PE. Valproic acid-induced hyperammonemic encephalopathy: MR appearance. AJNR Am J Neuroradiol 1994; 15: 1779–81
Ziyeh S, Thiel T, Spreer J, et al. Valproate-induced encephalopathy: assessment with MR imaging and 1H MR spectroscopy. Epilepsia 2002; 43: 1101–5
Hantson P, Grandin C, Duprez T, et al. Comparison of clinical, magnetic resonance and evoked potentials data in a case of valproic-acid-related hyperammonemic coma. Eur Radiol 2005; 15: 59–64
Robertson AS, Jain S, O’neil RA. Spongiform leucoencephalopathy following intravenous heroin abuse: radiological and histopathological findings. Australas Radiol 2001; 45: 390–2
Barnett MH, Miller LA, Reddel SW, et al. Reversible delayed encephalopathy following intravenous heroin overdose. J Clin Neurosci 2001; 8: 165–7
Wolters EC, van Wijngaarden GK, Stam FC, et al. Leukoencephalopathy after inhaling ‘heroin’ pyrolysate. Lancet 1982; II: 1233–7
Kriegstein AR, Shungu DC, Millar WS, et al. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation (‘chasing the dragon’). Neurology 1999; 53: 1765–73
Chen CY, Lee KW, Lee CC, et al. Heroin-induced spongiform leukoencephalopathy. J Comput Assist Tomogr 2000; 24: 735–7
Gacouin A, Lavoue S, Signouret T, et al. Reversible spongiform leukoencephalopathy after inhalation of heated heroin. Intensive Care Med 2003; 29: 1012–5
Keogh CF, Andrews GT, Spacey SD, et al. Neuroimaging features of heroin toxicity: ‘chasing the dragon’. AJR Am J Roentgenol 2003; 180: 847–50
Vella S, Kreis R, Lovblad KO, et al. Acute leukoencephalopathy after inhalation of a single dose of heroin. Neuropediatrics 2003; 34: 100–4
Maschke M, Fehlings T, Kastrup O, et al. Toxic leukoencephalopathy after intravenous consumption of heroin and cocaine with unexpected clinical recovery. J Neurol 1999; 246: 850–1
Ryan A, Molloy FM, Farrell MA, et al. Fatal toxic leukoencephalopathy: clinical, radiological, and necropsy findings in two patients. J Neurol Neurosurg Psychiatry 2005; 76: 1014–6
Reneman L, Habraken JB, Majoie CB, et al. MDMA (‘Ecstasy’) and its association with cerebrovascular accidents: preliminary findings. AJNR Am J Neuroradiol 2000; 21: 1001–7
Boulouri MR, Small GA. Neuroimaging of hypoxia and cocaine-induced hippocampal stroke. J Neuroimaging 2004; 14: 290–1
del Amo M, Berenguer J, Pujol T, et al. MR in trichloroethane poisoning. AJNR Am J Neuroradiol 1996; 17: 1180–2
Mutlu H, Silit M, Pekkafali Z, et al. Cranial MR imaging findings of potassium chlorate intoxication. AJNR Am J Neuroradiol 2003; 24: 1396–8
Chan YL, Ng HK, Leung CB, et al. 31Phosphorus and single voxel proton MR spectroscopy and diffusion-weighted imaging in a case of star fruit poisoning. AJNR Am J Neuroradiol 2002; 23: 1557–60
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Hantson, P., Duprez, T. The Value of Morphological Neuroimaging after Acute Exposure to Toxic Substances. Toxicol Rev 25, 87–98 (2006). https://doi.org/10.2165/00139709-200625020-00003
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DOI: https://doi.org/10.2165/00139709-200625020-00003