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Baroud S, Al Zaabi F, Gaba WH, El Lahawi M. Man-in-the-Barrel Syndrome Secondary to Idiopathic Acute Anterior Spinal Artery Infarction. Cureus 2023; 15:e41549. [PMID: 37554587 PMCID: PMC10405022 DOI: 10.7759/cureus.41549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
A 52-year-old female presented to our hospital with an acute history of isolated bilateral arm weakness. An MRI of the cervical spine confirmed an acute anterior spinal artery infarction. Further investigations to determine a specific etiology were unremarkable, leading to a diagnosis of idiopathic anterior spinal artery infarction consistent with Man-in-the-Barrel syndrome.
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Affiliation(s)
- Sarah Baroud
- Internal Medicine, Sheikh Khalifa Medical City, Abu Dhabi, ARE
| | - Fatima Al Zaabi
- Internal Medicine, Sheikh Khalifa Medical City, Abu Dhabi, ARE
| | - Waqar H Gaba
- Internal Medicine, Sheikh Khalifa Medical City, Abu Dhabi, ARE
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Yadav N, Pendharkar H, Kulkarni GB. Pediatric spinal cord infarct: a rare cause of a rare disorder, (wo)man in barrel syndrome. Childs Nerv Syst 2021; 37:2673-2676. [PMID: 33083875 DOI: 10.1007/s00381-020-04927-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
The "man in barrel syndrome" is a condition which resembles the aspect of patient being constrained in a barrel in which patient presents with bilateral upper limb weakness. It has classically been attributed to supratentorial lesions in watershed zones. We present such a case in a 12-year-old child who presented with bibrachial weakness and was noted to have cervical cord infarct on imaging. Spinal cord infarct is a rare cause of this syndrome, and until now only 20 cases have been described in which cervical cord infarct led to this presentation, all of them being adults. We describe first case report of bibrachial diplegia due to cord infarct in a child. Our case adds to the limited literature of cervical cord ischemia as a cause of "(wo) man in barrel syndrome" and re-iterates the fact that imaging of cervical cord should be considered while evaluating these cases.
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Affiliation(s)
- Nishtha Yadav
- Department of Radiology, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, 482003, India
| | - Hima Pendharkar
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India.
| | - Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India
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Kalampokini S, Artemiadis A, Zis P, Hadjihannas L, Parpas G, Kyrri A, Hadjigeorgiou GM. Osmotic demyelination syndrome improving after immune-modulating treatment: Case report and literature review. Clin Neurol Neurosurg 2021; 208:106811. [PMID: 34358802 DOI: 10.1016/j.clineuro.2021.106811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS), which embraces central pontine and extrapontine myelinolysis, is an uncommon neurological disorder that occurs due to plasma osmotic changes. CASE PRESENTATION We present the case of a 55-year-old man, who presented with severe hyponatremia due to repeated vomiting, antidepressant treatment and consumption of large amounts of water. Fifteen days after sodium correction, the patient showed fluctuation of vigilance, dysarthria and dysphagia, tremor, cogwheel rigidity, bilateral facial palsy, ophthalmoplegia and tetraparesis. A brain MRI scan revealed extrapontine and later on pontine myelinolysis. He received intravenous steroids and subsequently immunoglobulin. His status began to improve gradually after completion of immunoglobulin and at three month-follow-up had no neurological deficit. LITERATURE REVIEW A comprehensive literature search of all reported ODS cases that received immunoglobulin, steroids or plasmapheresis was conducted in the electronic databases PubMed and Web of science. CONCLUSIONS Improvement was seen in most cases that received immunoglobulin either during treatment or in the first days after treatment. With regard to steroids, although most cases reported improvement in the following months their effect on the outcome is unclear. Most cases treated with plasmapheresis reported favorable outcome at variable follow-up time. Immunoglobulin and steroids have immunomodulatory effects, which could contribute to promotion of myelin repair in ODS. Plasmapheresis has effects on the immune system beyond removing myelinotoxins from the circulation. More evidence is required to support their use in ODS. However, in view of the disease severity, these therapeutic choices should be considered in the clinical management of ODS.
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Affiliation(s)
- Stefania Kalampokini
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus.
| | - Artemios Artemiadis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Panagiotis Zis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Linos Hadjihannas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Giorgos Parpas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Artemis Kyrri
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Georgios M Hadjigeorgiou
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
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Abstract
"Person-in-the-barrel" syndrome is a descriptive term for bilateral arm (brachial) paresis in the absence of lower extremity (crural) weakness or bulbar (medullary) weakness. This phenomenon is associated with various descriptive terms such as "distal field infarction", "flail limbs", and "cruciate paralysis". Arriving at a specific diagnosis is a fascinating exercise in anatomical localization. Strategic lesions involving the watershed zones of the motor frontal lobes and the pyramidal decussation at the cervico-medullary junction are the classic sites of injury. However, peripheral causes such as motor neuron disease, mononeuritis multiplex (vasculitis), bilateral brachial plexopathy, and critical illness myopathy have been sporadically reported and can stochastically inflict the motor nerves or muscles of the upper extremities. In this report, we present a case of vasculitis with weakness restricted to the upper extremities and also delve into the neuropathological mechanisms of "person-in-the-barrel" syndrome.
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Abdul Halim S, Mohd Amin NA. Treatment response in osmotic demyelination syndrome presenting as severe parkinsonism, ptosis and gaze palsy. BMJ Case Rep 2018; 2018:bcr-2018-225751. [PMID: 30344146 DOI: 10.1136/bcr-2018-225751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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. MRI revealed typical features of central pontine and extrapontine myelinolysis. The patient improved gradually after treatment with a combination of levodopa, intravenous immunoglobulin and dexamethasone. However, it is important to emphasise that the improvement of neurological symptoms is not necessarily causal with these experimental therapies.
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Affiliation(s)
- Sanihah Abdul Halim
- Department of Medicine (Neurology), School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Nur Aida Mohd Amin
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Muñoz Amat B, Vázquez Román S, Gallego Herrero C, Núñez-Enamorado N, Toldos González Ó, Pallás Alonso CR. A Preterm Newborn With the "Barrel Syndrome". Pediatr Neurol 2017; 71:8-13. [PMID: 28390778 DOI: 10.1016/j.pediatrneurol.2017.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/21/2016] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
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Atchaneeyasakul K, Tipirneni A, Gloria S, Berry AC, Shah K, Yavagal DR. Osmotic demyelination syndrome: plasmapheresis versus intravenous immunoglobulin? Intern Emerg Med 2017; 12:123-126. [PMID: 27091143 DOI: 10.1007/s11739-016-1452-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kunakorn Atchaneeyasakul
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Anita Tipirneni
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Salomon Gloria
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Andrew C Berry
- Department of Medicine, University of South Alabama, 2451 Fillingim St., Mobile, AL, 36617-2238, USA.
| | - Kush Shah
- Department of Radiology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Dileep R Yavagal
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
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Rouanet C, Reges D, Rocha E, Gagliardi V, Uehara MK, Miranda MA, Silva GS. "Man in the Barrel" Syndrome with Anterior Spinal Artery Infarct due to Vertebral Artery Dissection. J Stroke Cerebrovasc Dis 2017; 26:e41-e42. [PMID: 28065615 DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/23/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Man in the barrel syndrome (MBS) is a condition of brachial diplegia initially described after a bilateral watershed cerebral infarct between the anterior and the middle cerebral artery territories. OBJECTIVE To report a case of MBS as a consequence of anterior spinal artery infarct due to vertebral artery dissection. DISCUSSION More recently, nonischemic lesions in brain and brain stem have also been described as etiologies of MBS. There are few reports describing spinal cord infarction leading to MBS. The anterior spinal artery syndrome with only brachial diplegia also represents a rare and atypical pattern. CONCLUSION The conventional neurological consideration that MBS provides a precise anatomical localization is now challenged. The finding of a brachial diplegia leads to the need to investigate the brain, the spinal cord, and the peripheral nervous system.
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Affiliation(s)
- Carolina Rouanet
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil.
| | - Danyelle Reges
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Eva Rocha
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Vivian Gagliardi
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Marcel Ken Uehara
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Maramelia Alves Miranda
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil
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Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol 2014; 170:G1-47. [PMID: 24569125 DOI: 10.1530/eje-13-1020] [Citation(s) in RCA: 436] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.
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Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ, Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler E. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant 2014; 29 Suppl 2:i1-i39. [PMID: 24569496 DOI: 10.1093/ndt/gfu040] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.
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Antelo MJG, Facal TL, Sánchez TP, Facal MSL, Nazabal ER. Man-in-the-barrel. A case of cervical spinal cord infarction and review of the literature. Open Neurol J 2013; 7:7-10. [PMID: 23407685 PMCID: PMC3568884 DOI: 10.2174/1874205x01307010007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 03/28/2012] [Accepted: 04/10/2012] [Indexed: 11/22/2022] Open
Abstract
Introduction: Man-in-the-barrel syndrome was initially observed in patients with signs of serious cerebral hypoperfusion, in the border zone of the anterior and medial cerebral artery, but other causes were communicated later. Methods: a healthy 43-year-old woman who showed intense cervical pain, irradiating over both shoulders and arms. Physical examination on admission highlighted notable brachial diparesis, tacto-algesic hypoesthesia of both arms and sensory level C4-D9. Results: cervical Magnetic Resonance Imaging (MRI) on admission revealed a hyperintense intramedullar lesion at C3-C7 level, due to a cervical cord infarction. Conclusions: our case reveals that conventional neurological consideration about the specific anatomical location of man-in-the-barrel syndrome in the brain should be extended to other locations such as the cervical column and not only the brain area.
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Affiliation(s)
- María José García Antelo
- Servicio de Neurología, Complexo Hospitalario Universitario A Coruña, C/ As Xubias, s/n. Código Postal 15006. A Coruña, Spain
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12
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Da Silva IRF. ‘Man-in-the-Barrel’ Syndrome with Bilateral 6th Cranial Nerve Palsy. Eur Neurol 2012; 68:367. [DOI: 10.1159/000342035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/22/2012] [Indexed: 11/19/2022]
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Lenk MR, Kaspar M. Sodium-reduced continuous venovenous hemodiafiltration (CVVHDF) for the prevention of central pontine myelinolysis (CPM) in hyponatremic patients scheduled for orthotopic liver transplantation. J Clin Anesth 2012; 24:407-11. [DOI: 10.1016/j.jclinane.2011.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 11/14/2011] [Accepted: 11/26/2011] [Indexed: 01/09/2023]
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Piccoli GB, Capobianco M, Odetto L, Deagostini MC, Consiglio V, Radeschi G. Acute renal failure, severe sodium and potassium imbalance and sudden tetraplegia. NDT Plus 2010; 3:247-252. [PMID: 28657059 PMCID: PMC5477952 DOI: 10.1093/ndtplus/sfq017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Revised: 01/09/2010] [Accepted: 02/10/2010] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Lorenzo Odetto
- Intensive Care Unit ASOU San Luigi, Orbassano, Torino, Italy
| | | | | | - Giulio Radeschi
- Intensive Care Unit ASOU San Luigi, Orbassano, Torino, Italy
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Davenport C, Liew A, Vic Lau P, Smith D, Thompson CJ, Kearns G, Agha A. Central pontine myelinolysis secondary to hypokalaemic nephrogenic diabetes insipidus. Ann Clin Biochem 2009; 47:86-9. [PMID: 19940203 DOI: 10.1258/acb.2009.009094] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Central pontine myelinolysis (CPM) has been described in alcoholic patients and in the aftermath of rapid correction of chronic hyponatraemia. We describe a case of CPM occurring secondary to nephrogenic diabetes insipidus (DI), which developed as a consequence of severe hypokalaemia. A 63-year-old man with alcohol dependence was admitted to hospital with severe pulmonary sepsis and type 1 respiratory failure. On admission, he had euvolaemic hyponatraemia of 127 mmol/L, consistent with a syndrome of inappropriate antidiuretic hormone secondary to his pneumonia. Following admission, his plasma potassium dropped from 3.2 to a nadir of 2.3 mmol/L. Mineralocorticoid excess, ectopic adrenocorticotrophic hormone production and other causes of hypokalaemia were excluded. The hypokalaemia provoked significant hypotonic polyuria and a slow rise in plasma sodium to 161 mmol/L over several days. Plasma glucose, calcium and creatinine were normal. The polyuria did not respond to desmopressin, and subsequent correction of his polyuria and hypernatraemia after normalization of plasma potassium confirmed the diagnosis of nephrogenic DI due to hypokalaemia. The patient remained obtunded, and the clinical suspicion of osmotic demyelination was confirmed on magnetic resonance imaging. The patient remained comatose and passed away 10 days later. This is the first reported case of nephrogenic DI resulting in the development of CPM, despite a relatively slow rise in plasma sodium of less than 12 mmol/L/24 h. Coexisting alcohol abuse, hypoxaemia and hypokalaemia may have contributed significantly to the development of CPM in this patient.
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Affiliation(s)
- C Davenport
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
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Zhang ZW, Kang Y, Deng LJ, Luo CX, Zhou Y, Xue XS, Wang D, Yin WH. Therapy of central pontine myelinolysis following living donor liver transplantation: Report of three cases. World J Gastroenterol 2009; 15:3960-3. [PMID: 19701983 PMCID: PMC2731265 DOI: 10.3748/wjg.15.3960] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We analyzed the clinical manifestations and experiences of diagnosing and treating central pontine myelinolysis following living donor liver transplantation. The clinical data of three patients with central pontine myelinolysis following living donor liver transplantation from January 2005 to November 2007 were retrospectively analyzed at the West China Hospital, Sichuan University, China. The three patients developed hyponatremia prior to surgery. Case 1 suffered locked-in syndrome following surgery, and received a large dose of gamma globulin, and subsequently recovered. Case 2 was in a coma for three days, and received hyperbaric chamber treatment. This patient remained in a mild coma for six months following surgery. Case 3 developed consciousness disturbances, gradually went into a coma following surgery, and died due to pulmonary infection. Central pontine myelinolysis is a severe complication in patients following living donor liver transplantation. Large-dose gamma globulin treatment, as well as hyperbaric oxygen, might be effective therapeutic methods.
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Abstract
The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11–S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5–S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.
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Affiliation(s)
- Andrei F. Joaquim
- 1University of Campinas (UNICAMP), Campinas SP, São Paulo, Brazil; and
| | | | - Charles A. Sansur
- 3Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Rughani AI, Visioni A, Hamill RW, Tranmer BI. Subclavian artery stenosis causing transient bilateral brachial diplegia: an unusual cause of anterior spinal artery syndrome. J Neurosurg Spine 2008; 9:191-5. [PMID: 18764753 DOI: 10.3171/spi/2008/9/8/191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The author report a case of a 74-year-old man who had presented with transient bilateral brachial diplegia. Investigations led to the diagnosis and treatment of subclavian artery stenosis. There are no known published cases of subclavian artery stenosis associated with transient bilateral arm weakness, and the authors believe that a steal phenomenon leading to vertebrobasilar artery insufficiency and subsequent anterior spinal artery insufficiency may have caused these symptoms, which resolved after correction of the patient's stenosis.
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Affiliation(s)
- Anand I Rughani
- Division of Neurosurgery, Department of Surgery, University of Vermont, College of Medicine, Burlington, Vermont, USA
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Abstract
Central pontine myelinolysis (CPM) can be regarded as one of the demyelinating syndromes. First described by Adams et al. in 1959 in their chronic alcoholic patients, it has now been described in the malnourished, the chronically debilitated, the renal, the hepatic and the transplant patient among others. Pathologically, it is defined as a symmetric area of myelin disruption in the center of the basis pontis, although similar symmetric lesions have also been described occurring with CPM as well as independently in other brain areas (extrapontine myelinolysis or EPM) including the cerebellar and neocortical white/gray junctional areas, thalamus and striatum. Possible mechanisms include a hyperosmotically induced demyelination process resulting from rapid intracellular/ extracellular to intravascular water shifts producing relative glial dehydration and myelin degradation and/or oligodendroglial apoptosis. The process most often occurs during rapid rebalancing of the electrolyte parameters in the hyponatremic patient. Avoidance of CPM/EPM is dependent upon recognizing those patients with conditions pre-disposing them to osmotic myelinolysis and then moderating the rate of normalization of the electrolyte imbalance. The morbidity and mortality of CPM/EPM has been greatly reduced by recognition of pre-disposing conditions, increased understanding of the pathophysiology, intensive treatment, and rapid diagnosis and monitoring with advanced neuroimaging.
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Affiliation(s)
- Suresh Kumar
- Department of Neurology, Louisiana State University School of Medicine, Shreveport, 71103, USA
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