Clinical and Radiologic Correlations of Central Pontine Myelinolysis Syndrome

doi:10.4065/mcp.2011.0239

Mayo Clinic Proceedings

Volume 86, Issue 11, November 2011, Pages 1063-1067

https://doi.org/10.4065/mcp.2011.0239 Get rights and content

OBJECTIVE

To characterize clinical and radiologic features of patients with central pontine myelinolysis (CPM) and identify variables that predict outcome.

PATIENTS AND METHODS

We retrospectively studied patients diagnosed as having CPM identified by a search of Mayo Clinic medical records from January 1, 1999, through December 31, 2010. Diagnosis was made by clinical and radiologic features. Favorable outcome was defined by a modified Rankin Scale score of 2 or lower. Volume of signal abnormality on brain magnetic resonance imaging (MRI) was quantified by a neuroradiologist blinded to outcomes. Wilcoxon rank sum tests were used to assess association between volume of signal abnormality and outcomes at discharge and last follow-up.

RESULTS

Of 24 patients, 14 (58%) had only CPM, and 10 (42%) had extrapontine involvement. Hyponatremia was documented in 18 patients (75%), with median sodium nadir of 114 mmol/L. Eighteen patients (75%) had alcoholism, and malnutrition was documented in 12 (50%). Presenting symptoms included encephalopathy (n=18 [75%]), ataxia (n=11 [46%]), dysarthria (n=7 [29%]), eye movement abnormalities (n=6 [25%]), and seizures (n=5 [21%]). Favorable outcome was seen in 15 patients (63%) at last follow-up. Findings on initial brain MRI were normal in 5 patients, but all MRI scans were abnormal with serial imaging. The volume of radiologic signal abnormality was not associated with outcome at discharge or last follow-up (P=.67 and P=.37, respectively).

CONCLUSION

Clinical outcome in patients with CPM is not predicted by the volume of radiologic T2 signal abnormality on MRI or the severity of hyponatremia. Serial brain imaging is of value because a substantial proportion of patients have normal findings on initial MRI.

Section snippets

PATIENTS AND METHODS

We performed a search for the terms central pontine myelinolysis, extrapontine myelinolysis, and/or osmotic demyelination using the Mayo Clinic medical records linkage system to identify patients with possible CPM who were evaluated at our institution between January 1, 1999, and December 31, 2010. This study was approved by the Mayo Clinic Institutional Review Board. Given our search, any case in which CPM was mentioned by the physician was identified (N=51). These medical records were

RESULTS

Of 24 patients, 13 (54%) were men, and the median age of the patients was 56 years (35, 92). Fourteen patients (58%) had only CPM, and 10 (42%) had extrapontine involvement. The suspected underlying causes of CPM were rapid correction of sodium (n=16 [67%]), hyperosmolar hyperglycemia (n=1 [4%]), and hyperammonemia (n=1 [4%]) and were unclear in 6 patients (25%). Eighteen patients (75%) had chronic alcoholism, and 12 (50%) had documented malnutrition with a median albumin level of 2.6 g/dL

DISCUSSION

In this retrospective series of patients with CPM and quantified MRI lesions, we found that the extent of T2 signal abnormality was not associated with clinical outcome. Although a prior study mentioned a similar clinicoradiologic disconnect (based on a single patient whose MRI results did not change despite clinical improvement),⁷ previous studies have not attempted to correlate severe radiologic abnormalities on MRI with clinical outcome. A persistently abnormal MRI signal after clinical

CONCLUSION

Neurologists are often asked to provide a prognosis after CPM because the clinical presentation can be catastrophic. Our study demonstrates that, although MRI is helpful in diagnosing CPM, the extent of pontine signal abnormality should not be considered a prognostic indicator. Patients with extensive pontine lesions can have a complete recovery. Further research is needed to help determine what factors might be important determinants of outcome after CPM.

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ORIGINAL ARTICLEClinical and Radiologic Correlations of Central Pontine Myelinolysis Syndrome

OBJECTIVE

PATIENTS AND METHODS

RESULTS

CONCLUSION

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

J Neurol Sci

Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholics and malnourished patients

Arch Neurol Psychiatry

Pontine and extrapontine myelinolysis

Brain

Central pontine myelinolysis following rapid correction of hyponatremia

Ann Neurol

Central pontine and extrapontine myelinolysis: a report of 58 cases

Clin Neuropathol

Central pontine and extrapontine myelinolysis: the osmotic demyelination syndromes

J Neurol Neurosurg Psychiatry

ORIGINAL ARTICLE
Clinical and Radiologic Correlations of Central Pontine Myelinolysis Syndrome