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J Neurosci Rural Pract 2019 Jan-Mar;10(1):126-135

Department of Internal Medicine, Max Super Speciality Hospital, New Delhi, India.

Osmotic demyelination syndrome is a rare entity characterized by noninflammatory demyelination afflicting the central pons, basal ganglia, thalami, peripheral cortex, and hippocampi. Histopathologically, there is a destruction of myelin sheaths sparing the underlying neuronal axons due to the susceptibility of oligodendrocytes to rapid osmotic shifts often encountered in chronically debilitated patients. We present the temporal progression of signal abnormalities on sequential magnetic resonance imaging (MRI) scans in a middle-aged male initially presenting with altered mental status due to severe hyponatremia and subsequently developing rigidity, diagnosed as osmotic demyelination syndrome based on typical imaging findings and supportive laboratory parameters. Read More

Lancet 2018 11;392(10160):2213

Department of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA.

Zhonghua Gan Zang Bing Za Zhi 2018 Oct;26(10):784-785

Department of Gastroenterology, The People's Hospital of Shanxi Province, Taiyuan 030012, China.

Cureus 2018 Sep 4;10(9):e3252. Epub 2018 Sep 4.

Internal Medicine, Shifa College of Medicine, Rawalpindi, PAK.

Central pontine myelinolysis is a rare condition arising from the myelinolysis of white matter tracts in the pons, most commonly in response to iatrogenic hypertonic stress caused by the rapid correction of hyponatremia. Here, we present an interesting case of central pontine myelinolysis subsequent to normal saline infusion despite strict adherence to the guideline protocol. Read More

BMJ Case Rep 2018 Oct 21;2018. Epub 2018 Oct 21.

Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Osmotic demyelination syndrome commonly affects the pons and infrequently involves the extrapontine region. We report a patient with severe hyponatraemia who developed osmotic demyelination syndrome as a consequence of rapid sodium correction. The condition manifested as acute severe parkinsonism, bilateral ptosis and gaze impairment. Read More

BMC Res Notes 2018 Oct 5;11(1):707. Epub 2018 Oct 5.

Department of Radiology, Medstar Washington Hospital Center, Washington, DC, USA.

Objective: This study describes the MRI changes associated with pontine and extrapontine myelinolysis secondary to rapid correction of hyponatremia in dogs. The authors discuss the relevance of the results for theories of pathogenesis and for diagnosis of patients.

Results: MRI changes associated with pontine and extrapontine myelinolysis first occur on diffusion-weighted imaging. Read More

World Neurosurg 2018 Oct 25;118:304-310. Epub 2018 Jul 25.

Department of Neurosurgery, Ramaiah Institute of Neurosciences, Ramaiah Medical College and Hospitals, Bangalore, India.

Background: Osmotic demyelination syndrome commonly follows rapid correction of hyponatremia. Although pons is a common location, extrapontine locations, such as striatum and thalamus, have been reported.

Case Description: A 48-year-old woman presented with masked facies, shuffling gait, and pill-rolling tremors suggestive of acute-onset parkinsonism. Read More

Anasthesiol Intensivmed Notfallmed Schmerzther 2018 Jul 23;53(7-08):492-502. Epub 2018 Jul 23.

Sodium is the most important osmotically effective cation in the extracellular space and very important for the water balance of the organism. Disturbances in the sodium homeostasis are therefore usually closely associated with disturbances in the water balance. The most important organs involved in the regulation of the sodium homeostasis are the kidneys and the brain. Read More

Case Rep Crit Care 2018 4;2018:4273971. Epub 2018 Jun 4.

Department of Pediatric Critical Care, Kapiolani Medical Center for Women & Children, USA.

Central pontine myelinolysis (CPM) is rarely reported in pediatric patients with diabetic ketoacidosis (DKA). We report this case of a 16-year-old female with new onset diabetes presenting with DKA, who received aggressive fluid resuscitation and sodium bicarbonate in the emergency department. Later she developed altered mental status concerning for cerebral edema and received hyperosmolar therapy with only transient improvement. Read More

Front Mol Neurosci 2018 12;11:204. Epub 2018 Jun 12.

Department of Neurobiology, The University of Alabama at Birmingham, Birmingham, AL, United States.

Maintenance of hydromineral balance (HB) is an essential condition for life activity at cellular, tissue, organ and system levels. This activity has been considered as a function of the osmotic regulatory system that focuses on hypothalamic vasopressin (VP) neurons, which can reflexively release VP into the brain and blood to meet the demand of HB. Recently, astrocytes have emerged as an essential component of the osmotic regulatory system in addition to functioning as a regulator of the HB at cellular and tissue levels. Read More

Clin J Am Soc Nephrol 2018 Jul 5;13(7):984-992. Epub 2018 Jun 5.

Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and

Background And Objectives: Rapid correction of severe hyponatremia can result in serious neurologic complications, including osmotic demyelination. Few data exist on incidence and risk factors of rapid correction or osmotic demyelination.

Design, Setting, Participants, & Measurements: In a retrospective cohort of 1490 patients admitted with serum sodium <120 mEq/L to seven hospitals in the Geisinger Health System from 2001 to 2017, we examined the incidence and risk factors of rapid correction and osmotic demyelination. Read More

Drug Saf Case Rep 2018 Apr 25;5(1):19. Epub 2018 Apr 25.

Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, 462 First Avenue, NBV 7N24, New York, NY, 10016, USA.

Desmopressin, a synthetic vasopressin analog, is used to treat central diabetes insipidus, hemostatic disorders such as von Willebrand's disease, and nocturnal enuresis. We present the case of a 69-year-old man who developed severe hyponatremia during treatment with intranasal desmopressin at 10 µg twice daily for chronic polyuria and nocturia thought to be due to central diabetes insipidus. After 5 months of therapy, the patient noticed progressive fatigue, anorexia, dizziness, weakness, light-headedness, decreased concentration, and new-onset falls. Read More

Child Neurol Open 2018 15;5:2329048X18770576. Epub 2018 Apr 15.

Division of Neurology, Children's Mercy Hospital, Kansas City, MO, USA.

An 11-month-old male presented with acute gastroenteritis, seizures, and altered mental status. Laboratory workup revealed serum sodium of 177 mmol/L. Magnetic resonance imaging of the brain showed reduced diffusion in the supratentorial white matter, T2 hyperintensities in the left central pons and midbrain, subacute stroke in the right occipital lobe, and bilateral cerebellar hemorrhagic infarcts. Read More

J Pediatr Neurosci 2017 Oct-Dec;12(4):353-355

Department of Pediatric Medicine, IPGMER and SSKM Hospital, Kolkata, West Bengal, India.

Accidental poisoning with Abrus precatorius (AP) can rarely produce neurological complication due to its toxic principle "Abrin". The authors report such a case in a 2-year old child, who subsequently developed central pontine myelinolysis, an association, to the best of the author's knowledge, has never been reported in literature. Read More

J Neurol Sci 2018 May 5;388:37-39. Epub 2018 Mar 5.

Unit of Neurology, Misericordia Hospital, Grosseto, Italy.

Emerg Radiol 2018 Aug 6;25(4):435-440. Epub 2018 Apr 6.

Department of Neuroimaging and Interventional Radiology, NIMHANS, Bangalore, 560029, India.

Acute neurovascular events, though rare, can complicate pregnancy and postpartum period. It is important to be aware of these clinical conditions for reducing maternal and fetal morbidity and mortality. In this review, we present a few important neurovascular emergencies and their imaging manifestations by various imaging modalities-computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA)-which presented at our institution in the peripartum period. Read More

BMC Res Notes 2018 Mar 14;11(1):177. Epub 2018 Mar 14.

National Hospital, Colombo, Sri Lanka.

Background: The pathogenesis of osmotic demyelination syndrome is not completely understood and usually occurs with severe and prolonged hyponatremia, particularly with rapid correction. It can occur even in normonatremic patients, especially who have risk factors like alcoholism, malnutrition and liver disease. Bilateral tongue fasciculations with denervation pattern in electromyogram is a manifestation of damage to the hypoglossal nucleus or hypoglossal nerves. Read More

BMC Endocr Disord 2018 Mar 12;18(1):18. Epub 2018 Mar 12.

Department of Internal Medicine II, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.

Background: Here, we report a case of central pontine demyelinization in a type-2 diabetes patient with hyperglycemia after a binge-eating attack in the absence of a relevant hyponatremia.

Case Presentation: A 55-year-old, male type-2 diabetic patient with liver cirrhosis stage Child-Pugh B was admitted due to dysmetria of his right arm, gait disturbance, dizziness, vertigo, and polyuria, polydipsia after a binge-eating attack of sweets (a whole fruit cake and 2 Liters of soft drinks). A recently initiated insulin therapy had been discontinued for 8 months. Read More

Medicine (Baltimore) 2018 Feb;97(8):e9878

Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Rationale: Marchiafava-Bignami disease (MBD) is a rare disease characterized by demyelination of the corpus callosum. It is most commonly seen in patients with chronic alcoholism. The clinical diagnosis of MBD can be difficult due to its nonspecific manifestation. Read More

Neurol Sci 2018 06 10;39(6):1133-1136. Epub 2018 Feb 10.

Dr. S.N. Medical College Jodhpur, Jodhpur, Rajasthan, India.

Am J Kidney Dis 2018 Mar 23;71(3):436-440. Epub 2017 Dec 23.

Division of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX; Division of Nephrology, Department of Medicine, Methodist Hospital, Houston, TX; Renal Section, Veterans Affairs Medical Center, Houston, TX.

Osmotic demyelination unrelated to hyponatremia is rarely reported. We present a case of osmotic demyelination in a patient with hypernatremia in the absence of preceding hyponatremia and review previously reported cases of osmotic demyelination in nonhyponatremic patients. We conclude that a rapid increase in serum sodium concentration and plasma tonicity even in the absence of preceding hyponatremia may surpass the brain's capacity for adaptation to hypertonicity and lead to osmotic demyelination in predisposed individuals. Read More

Acta Neurol Taiwan 2017 Jun;26(2):64-67

Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.

Purpose: The osmotic demyelination syndrome (ODS) has been identified as a neurological complication of the rapid correction of hyponatremia. In recent years, however, various medical conditions have been associated with the development of ODS, irrelevant to changes in serum sodium. We present a rare case of a eunatremic patient who developed ODS with manifestation of parkinsonism. Read More

Transplant Proc 2017 Dec;49(10):2399-2401

Department of Pulmonary and Critical Care, Emory University, Atlanta, Georgia; Department of Transplant Hepatology, Emory University, Atlanta, Georgia. Electronic address:

Severe hyponatremia can complicate the pretransplantation management of patients with decompensated cirrhosis while they await liver transplantation. Before the liver transplant, it is critical to correct severe hyponatremia to an appropriate level to reduce the risks of perioperative complications such as central pontine myelinolysis, cerebral edema, and seizures. Vasopressin receptor antagonists, and in particular tolvaptan, offer a therapeutic modality that can correct severe refractory hyponatremia in a timely and predictable manner before liver transplantation. Read More

Forensic Sci Med Pathol 2018 03 25;14(1):106-108. Epub 2017 Nov 25.

Department of Neuropathology, North Bristol NHS Trust, Bristol, UK.

Central pontine myelinolysis (CPM) is a neurological demyelinating disease of the pons. Although usually associated with rapid correction of hyponatremia, CPM may occur despite normonatremia, is often associated with chronic alcoholism and may be asymptomatic. Histological confirmation of asymptomatic CPM is rare. Read More

Neurologia 2017 Nov 20. Epub 2017 Nov 20.

Departamento Neurología, Hospital Universitario de Getafe, Getafe, Madrid, España.

Indian J Nucl Med 2017 Oct-Dec;32(4):333-335

Department of Nuclear Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India.

A rare acquired demyelinating lesion of the pons central pontine myelinolysis (CPM) typically occurs after rapid correction of hyponatremia. There is disruption of blood-brain barrier due to osmotic stress allowing access for inflammatory mediators in extravascular brain tissue, which most likely attracts glial cells of the brain, attracts macrophages, and activates astrocytes. We present a case of female with a known history of inflammatory bowel disease who presented with altered sensorium and hyponatremia. Read More

Exp Clin Transplant 2017 Nov 15. Epub 2017 Nov 15.

From the Department of Nursing, Changhua Christian Hospital, Changhua, Taiwan.

Here, we present 2 patients who developed central pontine myelinolysis after living-donor liver transplant. Both patients had abnormal sodium level before living-donor liver transplant. Patient 1 presented with severe hyponatremia on admission. Read More

WMJ 2016 12;115(6):326-8

Central pontine myelinolysis (CPM) is a rare phenomenon that causes significant morbidity and mortality. Active therapeutic interventions for CPM can have a positive impact on recovery and overall prognosis. This case represents a 34-year-old white man with a chronic history of alcohol abuse who had Parkinsonian symptoms 13 days after rapid correction of his serum sodium in the hospital. Read More

Handb Clin Neurol 2017 ;145:175-180

Department of Forensic Medicine, University of Rostock, Rostock, Germany.

Alcohol abuse and dependence are serious medical and economic problems in Western countries. Brain changes encountered in alcoholism are manifold and encompass brain atrophy, selective neuronal loss, astroglial, and microglial changes. Alcohol-related disorders are complex multifactorial disorders where the interaction of multiple genes and environment plays an important role in the pathogenesis. Read More

Endocrinol Diabetes Metab Case Rep 2017 4;2017. Epub 2017 Sep 4.

Endocrinology, Guthrie Robert Packer Hospital, Sayre, Pennsylvania, USA.

Central pontine myelinolysis (CPM) usually occurs with rapid correction of severe chronic hyponatremia. Despite the pronounced fluctuations in serum osmolality, CPM is rarely seen in diabetics. This is a case report of CPM associated with hyperglycemia. Read More

Neurol Sci 2018 01 15;39(1):193-195. Epub 2017 Sep 15.

Department of Biomedical, Metabolic, and Neural Sciences, N.O.C.S.A.E. Hospital, AOU Modena, University of Modena and Reggio Emilia, 41100, Modena, Italy.

Childs Nerv Syst 2017 11 13;33(11):1881-1882. Epub 2017 Sep 13.

Department of Neurosurgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, IN, USA.

J La State Med Soc 2017 Jul-Aug;169(4):89-93. Epub 2017 Aug 28.

Department of Radiology, Tulane University Health Sciences Center - New Orleans, LA.

Osmotic demyelination syndrome (ODS) is a general term that has become commonplace in the practice of medicine, encompassing both central pontine myelinolysis and extrapontine myelinolysis. Historically ODS arises as a serious complication of rapid correction of hyponatremia, yet its manifestations seem to be influenced by a multifactorial process. Further understanding of this rare demyelinating disease has elucidated the significant role of other electrolyte disturbances and the presence of chronic comorbidities as disease risk factors. Read More

Neurol Sci 2017 12 7;38(12):2223-2225. Epub 2017 Aug 7.

Department of Neurology, Hazrat Rasool Hospital, Iran University of Medical Sciences, Niyayesh St, Sattarkhan Ave, Tehran, 1445613131, Iran.

Presse Med 2017 Oct 27;46(10):968-970. Epub 2017 Jul 27.

Rouen university hospital, department of anesthesiology and intensive care, 76031 Rouen, France.

Med Hypotheses 2017 Jul 10;104:10-14. Epub 2017 May 10.

Helios-Klinikum Pirna, Struppener Straβe 13, D-01796 Pirna, Saxony, Germany. Electronic address:

Due to the elastic properties of the human organs, tissue edema causes an increased tissue pressure. This phenomenon leads to a reduction of blood circulation or ischemia, and thus leads to the hypothesis that tissue edema can be the cause of demyelinating lesions. Even though brain edema occurs in the whole brain, the authors assume that the characteristically focal appearance of demyelinated lesions, for instance of multiple sclerosis plaques, are attributable to anatomical and structural characteristics of the brain. Read More

J Assoc Physicians India 2017 May;65(5):88

Senior Resident.

Rev Neurol (Paris) 2018 Jan - Feb;174(1-2):66-67. Epub 2017 Jun 2.

Department of internal medicine, university hospital and medical school of Oran, centre hospitalier universitaire d'Oran, 76, boulevard du Dr-Benzerdjeb, 31000 Oran, Algeria.

Neurology 2017 05;88(22):e207-e211

From the Department of Neurology (J.R.), University of Rochester Medical Center; and University of Rochester School of Medicine (M.W.), NY.

BMJ Case Rep 2017 May 12;2017. Epub 2017 May 12.

Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India.

Central pontine myelinolysis (CPM) is a demyelinating disorder of central nervous system which involves central portion of the pons and sometimes extrapontine areas also. It is commonly reported in settings of hyponatraemia or its rapid correction, but in the last few years it has also been reported in patients with diabetes in the absence of electrolyte disturbances or correction of serum osmolality. Here we report a case of a 20-year-old female patient, with a known history of type 1 diabetes mellitus, who presented with acute onset spastic quadriparesis with dysarthria and mild ataxia which evolved over 2 weeks. Read More

Neurol India 2017 May-Jun;65(3):674-675

Department of Pathology, B.Y.L Nair Hospital, Mumbai, Maharashtra, India.

J Assoc Physicians India 2017 Mar;65(3):98-99

Junior Resident, Department of Medicine, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh.

Osmotic demyelination syndrome is classically associated with rapid correction of hyponatremia. However, it can occur in normonatremic patients with other electrolyte abnormalities. One must suspect osmotic demyelination syndrome in susceptible patients with other electrolyte abnormalities like hypokalemia and hypophosphatemia. Read More

BMJ Case Rep 2017 Apr 26;2017. Epub 2017 Apr 26.

Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

A 44-year-old man presented with history of slurring of speech, slowness in activities, abnormal posturing of the upper limbs and drooling of saliva from the mouth. He had a 5-yearlong history of compulsive water drinking, consuming 12-15 L of water every day. He was earlier evaluated for the same and found to have low serum sodium (126 mEq/L). Read More

Fortschr Neurol Psychiatr 2017 Apr 24;85(4):212-215. Epub 2017 Apr 24.

Neurologie, Sankt Katharinen Krankenhaus, Frankfurt am Main.

Hyponatremia and its rapid correction is a well-known cause of osmotic demyelination most commonly affecting the pons. We report on a case of severe hyponatremia likely due to psychogenic polydipsia resulting in hypotonic hyperhydration with resulting cortical laminar necrosis on initial imaging, mimicking hypoxic brain damage. Pontine myelinolysis became apparent on follow-up imaging, illustrating the diagnostic challenges of extrapontine manifestations of severe hyponatremia. Read More

J Pediatr 2017 07 18;186:207-207.e1. Epub 2017 Apr 18.

The Warren Alpert Medical School of Brown University; Pediatric Endocrinology Rhode Island Hospital Providence, Rhode Island.

Case Rep Neurol Med 2017 14;2017:1471096. Epub 2017 Mar 14.

Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA; Illinois Neurological Institute, OSF St. Francis Medical Center, Peoria, IL, USA.

Central pontine myelinolysis (CPM) is an acute demyelinating neurological disorder affecting primarily the central pons and is frequently associated with rapid correction of hyponatremia. Common clinical manifestations of CPM include spastic quadriparesis, dysarthria, pseudobulbar palsy, and encephalopathy of various degrees; however, coma, "locked-in" syndrome, or death can occur in most severe cases. Rarely, CPM presents with neuropsychiatric manifestations, such as personality changes, acute psychosis, paranoia, hallucinations, or catatonia, typically associated with additional injury to the brain, described as extrapontine myelinolysis (EPM). Read More

Zh Nevrol Psikhiatr Im S S Korsakova 2017;117(2):117-123

City Scientific and Practical Center of Tuberculosis, Moscow, Russia.

A case report of central pontine and extrapontine myelinolysis in the combination with spinal cord damage is presented. The authors analyze literature data on this problem and discuss the pathogenesis and diagnostic issues of myelinolysis. Read More

Neuro Endocrinol Lett 2016 Nov;37(6):415-418

Department of Neurology, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.

Objectives: Osmotic demyelination syndrome (ODMS) is a rare and serious neurologic disorder with acute myelin disintegration, usually in the pontine area (central pontine myelinolysis) and to a lesser extent, even in other areas of the central nervous system (extrapontine myelinolysis). The main underlying mechanism is the change of serum osmolality with quick correction of low mineral levels, mainly hyponatraemia. Clinical manifestation is various and depends on the localization. Read More

Ann Rehabil Med 2017 Feb 28;41(1):148-152. Epub 2017 Feb 28.

Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea.

Central pontine myelinolysis (CPM) is a demyelinating disorder characterized by the loss of myelin in the center of the basis pons, and is mainly caused by the rapid correction of hyponatremia. We report the case of a young woman who presented with gait disturbance and alcohol withdrawal, and who was eventually diagnosed with CPM. Generally, the cause and pathogenesis of CPM in chronic alcoholics remain unclear. Read More

J Clin Med Res 2017 Apr 21;9(4):266-272. Epub 2017 Feb 21.

Division of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori,"Fondazione Giovanni Pascale" IRCCS, via Mariano Semmola, 52, 80131 Napoli, Italy.

This review aims at summarizing essential aspects of epidemiology and pathophysiology of hyponatremia in chronic heart failure (CHF), to set the ground for a practical as well as evidence-based approach to treatment. As a guide through the discussion of the available evidence, a clinical case of hyponatremia associated with CHF is presented. For this case, the severe neurological signs at presentation justified an emergency treatment with hypertonic saline plus furosemide, as indicated. Read More