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Continuum (Minneap Minn) 2020 Jun;26(3):632-658

Purpose Of Review: This article provides an overview of the major electrolyte disorders and discusses in detail the homeostasis, etiologies, neurologic manifestations, and treatment of these disorders.

Recent Findings: The diagnosis and management of hyponatremia continue to evolve. Diagnostic accuracy is improved by assessing serum and urine osmolality as well as urinary sodium. Read More

World Neurosurg 2020 May 13. Epub 2020 May 13.

Institute of Neuroradiology, Cantonal Hospital, Aarau, Switzerland.

An elderly woman was transferred for biopsy of a pontine lesion. Her condition, including gait disturbances, truncal ataxia, and dysarthria - presumed to be due to a history of severe alcohol abuse - deteriorated over the course of treatment for ambulatory-acquired pneumonia. No electrolyte abnormalities were noted during hospitalization. Read More

Mov Disord Clin Pract 2020 Apr 16;7(3):335-337. Epub 2020 Mar 16.

Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla Seville Spain.

Pan Afr Med J 2019 20;34:208. Epub 2019 Dec 20.

Service d'Accueil des Urgences Vitales, Département d'Anesthésie Réanimation et Urgences, Hôpital Ibn Tofail, CHU Mohammed VI, Faculté de Médecine et de Pharmacie de Marrakech, Université Cadi Ayyad, Marrakech, Maroc.

Osmotic demyelination syndrome is characterized by the loss of myelin in the center of the basis pontis and other areas of the central nervous system. We report a case of osmotic demyelination syndrome in a 55-year-old female, with a past medical history of arterial hypertension and multi-level cervical spondylosis, hospitalized for acute altered mental status complicating an array of acute gastroenteritis, the patient was afebrile. The course was marked by neurologic aggravation with confusion, aphasia, tetraplegia and osteo-tendinous areflexia. Read More

Neurol India 2020 Jan-Feb;68(1):146-151

Department of Neurology, Faculty of Medicine, Cairo University, Giza, Egypt.

Background And Aim: Liver transplantation (LT) is the only curative treatment for patients with the end-stage liver disease. Amongst the complications post-LT, the neurological complications (NC) are particularly relevant. Our aim is to assess the incidence, risk factors and clinical presentation of NC in recipients after living donor liver transplantation. Read More

Clin Neurol Neurosurg 2020 May 5;192:105722. Epub 2020 Feb 5.

Department of Neurology, Hospital Main-Spessart, Grafen-von-Rieneck-Str. 5, 97816, Lohr, Germany; University Clinic Würzburg, Department of Neurology, Josef-Schneider-Str. 11, 97080, Würzburg, Germany. Electronic address:

Chin Med J (Engl) 2020 Apr;133(7):874-876

Department of Neurology, The Affiliated Hospital of Jiujiang University, Jiujiang, Jiangxi 332000, China.

Cureus 2020 Jan 2;12(1):e6547. Epub 2020 Jan 2.

Internal Medicine, Martini Hospital, Groningen, NLD.

This case report describes a 57-year-old man who presented first with lethargy and dysarthria due to hyponatremia resulting from poor intake and diuretics. One week after discharge, he returned with confusion, ataxia and dysphagia, and he ultimately turned out to have developed an osmotic demyelination syndrome (ODS). In his first hospital admission, his serum sodium was corrected without new neurological symptoms occurring. Read More

Med Klin Intensivmed Notfmed 2020 Feb 2;115(1):29-36. Epub 2019 Dec 2.

Klinikum Braunschweig, Medizinische Klinik V (Nephrologie Ɩ Rheumatologie Ɩ Blutreinigungsverfahren), Salzdahlumer Straße 90, 38126, Braunschweig, Deutschland.

Hyponatremia (sodium <135 mmol/l) is the most common electrolyte disorder. Despite identical serum concentrations, clinical symptomatology can vary greatly from mild to life-threatening. Accordingly, individual patients require immediate active treatment, while the majority of (mostly oligosymptomatic) patients should first undergo differentiated diagnosis. Read More

Am J Emerg Med 2020 Mar 16;38(3):690.e3-690.e5. Epub 2019 Nov 16.

Department of Emergency Medicine, Brody School of Medicine at East Carolina University, Greenville, NC 27834, USA.

Emergency physicians frequently treat hyperemesis gravidarum and should be aware of possible complications. Wernicke encephalopathy secondary to thiamine deficiency should be considered in the differential diagnosis of acute encephalopathy in pregnant women. A seventeen-week pregnant 27-year-old woman presented to the Emergency Department with nausea, emesis, and right upper quadrant abdominal pain. Read More

Dtsch Arztebl Int 2019 Sep;116(35-36):600-606

Department of Neurology and Neurophysiology, University Medical Center Freiburg, Germany.

Background: Osmotic demyelination syndrome (ODS), which embraces central pontine myelinolysis (CPM) and extrapontine myelinosis (EPM), is often underdiagnosed in clinical practice, but can be fatal. In this article, we review the etiology, patho- physiology, clinical features, diagnosis, treatment, and prognosis of ODS.

Methods: Pertinent publications from the years 1959 to 2018 were retrieved by a selective search in PubMed. Read More

Indian J Psychol Med 2019 Sep-Oct;41(5):491-493. Epub 2019 Sep 5.

Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.

J Pediatr Neurosci 2019 Apr-Jun;14(2):97-99

Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, New Delhi, India.

The objective of this study was to report a case of central pontine and extrapontine myelinolysis in a child, a rare neurological disorder. A diagnosis of demyelination carries important therapeutic and prognostic implications. In most cases, the diagnosis is made clinically and confirmed radiologically. Read More

Pract Neurol 2020 Feb 29;20(1):64-65. Epub 2019 Aug 29.

Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Niger J Clin Pract 2019 Aug;22(8):1166-1168

Department of Medicine, Abubakar Tafawa Balewa University Teaching Hospital, PMB 0117, Bauchi, Bauchi State, Nigeria.

Osmotic demyelination syndrome (ODS) is a life-threatening neurological condition often associated with rapid correction of hyponatremia. While ODS is thought to be rare, with prevalence rates of not more than 0.5% in autopsy series, mortality rates are as high as 90% in some studies. Read More

Int J Neurosci 2019 Dec 1;129(12):1226-1233. Epub 2019 Sep 1.

Department of Physiology and Biophysics, Stony Brook University Renaissance School of Medicine , New York , NY , USA.

Porphyrias are inherited disorders of the heme biosynthetic pathway, usually characterized by dermatological changes due to the accumulation of byproducts in the pathway. Select porphyrias also affect the nervous system, namely hereditary coproporphyria, acute intermittent porphyria and variegate porphyria. Complications include paralysis, hyponatremia which can risk central pontine myelinolysis, seizures and coma. Read More

Endocrinol Diabetes Metab Case Rep 2019 May 30;2019(1). Epub 2019 May 30.

Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK

Summary: Hypokalaemia at presentation of diabetic ketoacidosis is uncommon as insulin deficiency and metabolic acidosis shifts potassium extracellularly. However, hypokalaemia is a recognised complication of the management of diabetic ketoacidosis as insulin administration and correction of metabolic acidosis shifts potassium intracellularly. We describe the case of a 9-year-old girl with newly diagnosed type 1 diabetes mellitus presenting in diabetic ketoacidosis, with severe hypokalaemia at presentation due to severe and prolonged emesis. Read More

Intensive Care Med Exp 2019 Jul 25;7(Suppl 1):45. Epub 2019 Jul 25.

Hospital Universitario de Getafe, Madrid, Spain.

Background: Sepsis is a highly lethal disorder. Organ dysfunction in sepsis is not defined as a clinicopathological entity but rather by changes in clinical, physiological, or biochemical parameters. Pathogenesis and specific treatment of organ dysfunction in sepsis are unknown. Read More

Acta Neurol Scand 2019 Nov 19;140(5):342-349. Epub 2019 Aug 19.

Department of Neurology, The National University Hospital of Iceland, Reykjavik, Iceland.

Objective: To report the incidence rate of osmotic demyelination syndrome (ODS), associated risk factors, treatment, and long-term outcomes in a nationwide cohort.

Methods: We conducted a retrospective study of individuals diagnosed with central pontine myelinolysis (ICD-10 code G37.2) in the Swedish National Patient Register during 1997-2011. Read More

Pediatr Neurol 2019 08 28;97:12-17. Epub 2019 Mar 28.

Department of Radiology, Children's Mercy Hospital, Kansas City, Missouri.

Osmotic demyelination syndrome is an acute demyelination process that usually occurs several days following an osmotic stress. This syndrome is rare in adults (0.4% to 0. Read More

Circ J 2019 06 22;83(7):1520-1527. Epub 2019 May 22.

Otsuka Pharmaceutical Co., Ltd.

Background: In Japan, tolvaptan is indicated for patients with heart failure and volume overload who have inadequate response to other diuretics. In contrast to the USA and Europe, tolvaptan can be used in Japan in patients with normal sodium levels.Methods and Results:In this multicenter, non-interventional, post-marketing surveillance study, prospective data from 3,349 patients treated with tolvaptan over a 5-year period were analyzed to identify benefits and risks. Read More

Ann Hepatol 2019 Jul - Aug;18(4):651-654. Epub 2019 Apr 24.

Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada. Electronic address:

Rapid overcorrection of chronic hyponatremia can lead to osmotic demyelination syndrome or central pontine myelinolysis (CPM), a diagnosis often triggered by observing the characteristics of neurological abnormalities developed as a result of CPM. However, anyone with chronic hyponatremia and overcorrection of serum sodium is at risk of physiological CPM despite the lack of clinical symptoms. We report an adult patient who presented as post-op delirium, had incidental finding of CPM by magnetic resonance imaging (MRI) of the head after a liver transplant. Read More

Medicine (Baltimore) 2019 Apr;98(17):e15261

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

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. Read More

Disabil Rehabil 2019 Apr 5:1-7. Epub 2019 Apr 5.

a Department of Rehabilitation , Casa Colina Hospital and Centers for Healthcare , Pomona , CA , USA.

Background: Central pontine myelinolysis is a rare condition that can result in debilitating symptoms. Recent evidence suggests a shift in hypothesized prognosis for individuals with this diagnosis and implies a valuable role for rehabilitation to address prevention of secondary complications and functional recovery. This paper describes a 30 year-old female with central pontine myelinolysis presenting with incomplete locked-in syndrome and chronicles her rehabilitative journey at a comprehensive post-acute rehabilitation center. Read More

Front Med (Lausanne) 2019 15;6:47. Epub 2019 Mar 15.

Division of Nephrology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.

Hyponatremic encephalopathy is a potentially life-threatening condition with a high associated morbidity and mortality. It can be difficult to diagnose as the presenting symptoms can be non-specific and do not always correlate with the degree of hyponatremia. It can rapidly progress leading to death from transtentorial herniation. Read More

Neuropathology 2019 Apr 4;39(2):156-161. Epub 2019 Mar 4.

Department of Neurology, Osaka City Kosaiin Hospital, Osaka, Japan.

An 80-year-old man with a history of diabetes mellitus and hypertension died of a progressive neurological disorder characterized by truncal ataxia, extraocular movement disturbance, and muscular rigidity. Neuroradiological examination showed progressive atrophy restricted to the pontine base. Autopsy revealed localized atrophy of the pontine base, in which both neurons and nerve fibers were lost, especially in the central region. Read More

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

Saudi J Kidney Dis Transpl 2018 Nov-Dec;29(6):1511-1514

Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India.

Neurotoxic manifestations due to chronic metronidazole intake are well known, but neurotoxicity due to short-term use of metronidazole is very rare. We present a case of acute neurotoxicity due to short course of injectable metronidazole given in usual doses to a renal allograft recipient for persistent diarrhea. It responded to withdrawal of the offending drug. Read More

Expert Rev Clin Pharmacol 2019 Jan 11;12(1):61-90. Epub 2019 Jan 11.

a Department of Neurology and Psychiatry , Assiut University Hospital , Assiut , Egypt.

: Uremic syndrome of chronic kidney disease (CKD) is a term used to describe clinical, metabolic, and hormonal abnormalities associated with progressive kidney failure. It is a rapidly growing public health problem worldwide. Nervous system complications occur in every patient with uremic syndrome of CKD. 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

Pediatr Neurol 2018 12 19;89:68-70. Epub 2018 Sep 19.

Nationwide Children's Hospital, Columbus, Ohio.

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

Liver Transpl 2018 11;24(11):1612-1621

GI/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.

Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. 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 07 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

JAMA Neurol 2018 07;75(7):888-889

Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.

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 05 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