Central pontine myelinolysis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

On the basis central pontine myelinolysis must be differentiated diseases that cause acute confusion, lethargy, speech difficulties and bilateral weakness or quadriplegia such as: Posterior leukoencephalopathy syndrome, infective encephalitis, ischemic Brain stem infarction, thalamus infarction due thrombosis of the basilar artery, diffuse hypoxic encephalopathy, metastasis to the brain and brain tumors such as glioma.

Differentiating central pontine myelinolysis from other Diseases

On the basis central pontine myelinolysis must be differentiated diseases that cause acute confusion, lethargy, speech difficulties and bilateral weakness or quadriplegia such as:

• Posterior leukoencephalopathy syndrome
• Hypertensive encephalopathy
• Infective encephalitis
• Ischemic Brain stem infarction
• Thalamus infarction due thrombosis of the basilar artery
• Diffuse hypoxic encephalopathy
• Metastasis to the brain
• Brain tumors such as glioma

Diseases	Clinical manifestations			Para-clinical findings		Gold standard	Additional findings
				Lab Findings	Imaging
	Confusion	Weakness and quadriplegia	Speech difficulties	Hypoosmotic hyponatremia	MRI
Central pontine myelinolysis	++	++	++	++	Symmetric signal intensity abnormality in the central pons at T2-weighted and FLAIR imaging Decreased T1 signal intensity Fluid attenuated inversion recovery (FLAIR) hyperintense lesion in the pons Intramedullary central T2 hyperintensity at axial T2W of spinal cord and sagittal T2W of thoracic spinal cord	MRI	The most common cause of central pontine myelinolysis is rapid correction(>48-hours duration) of hyponatremia in patients with the history of prolonged hyponatremia
Posterior leukoencephalopathy syndrome	++	-/+	-/+	-	Multiple cortico-subcortical areas of T2-weighted hyperintense signal involving the occipital and parietal lobes bilaterally and pons.	MRI	Other symptoms include: Seizure, headache, visual disturbances, focal neurologic signs, and status epilepticus. Many cases resolve within 1–2 weeks of controlling blood pressure and eliminating the inciting factor.
Ischemic Brain stem infarction	-/+	+	-/+	-	Abnormal high signal within the brainstem white matter and gray matter	MRI	The brain stem infarct can affect essential body functions, such as: Breathing Swallowing Eye movement Facial movement and sensation Hearing Heart rate Blood pressure Body temperature
Hypertensive encephalopathy	-/+	-/+	+	-	Diffuse extensive periventricular deep white matter T2 hyperintensity changes Ex vacuo ventriculomegaly Global, symmetrical, supra and infratentorial involutional changes	MRI	Symptoms typically start to occur 12–48 hours after a sudden and sustained increase in blood pressure. The first symptom is a severe headache. Other symptoms include: Impaired judgement and memory
Infective encephalitis	-/+	-/+	-/+	-	High signal in both white and grey matter Region of hypodensity	MRI	Viruses are the most common cause of infectious encephalitis. Bacteria, fungus and parasites also can cause infectious encephalitis