title: Osmotic myelinolysis with malignant cerebellar edema occurring after DDAVP-induced hyponatremia in a child.
abstract: Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are dire neurological disorders, characterized by severe damage to the myelin sheath of neurons, which typically result from rapid correction or overcorrection of systemic hyponatremia. For many years, both conditions have been considered universally fatal, though survivors have been reported more recently. Pediatric cases are rare. We present a 13-year-old boy with panhypopituitarism secondary to repair of a nasofrontal encephalocele in infancy, managed on long-term corticosteroid, deamino arginine vasopressin and thyroid hormone. He presented with severe hyponatremia (116 mEq/l), which during correction rapidly and unexpectedly increased to 176 mEq/l, resulting in profoundly impaired consciousness. Brain imaging revealed multiple bilateral changes in the basal ganglia, thalamus, pons and cerebral white matter, consistent with both CPM and EPM. Malignant cerebellar edema necessitated emergent suboccipital craniectomy, with subsequent improvement in level of consciousness and imaging postoperatively. However, he succumbed to acute cardiorespiratory arrest 8 weeks later. Nine similar cases from the literature are reviewed.
authors.affiliation: Pediatric Neurosurgery, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont., Canada. aranger@uwo.ca
authors.forename: Adrianna
authors.initials: A
authors.lastname: Ranger
authors.forename: Artur
authors.initials: A
authors.lastname: Szymczak
authors.forename: Simon
authors.initials: S
authors.lastname: Levin
authors.forename: Marina
authors.initials: M
authors.lastname: Salvadori
authors.forename: Douglas D
authors.initials: DD
authors.lastname: Fraser
mesh_terms: D000293:Adolescent; D050034:Antidiuretic Agents / Q000009:adverse effects; D001929:Brain Edema / Q000209:etiology / Q000378:metabolism* / Q000473:pathology; D002531:Cerebellum / Q000378:metabolism / Q000473:pathology; D003894:Deamino Arginine Vasopressin / Q000009:adverse effects*; D006801:Humans; D007010:Hyponatremia / Q000139:chemically induced* / Q000150:complications / Q000473:pathology; D008279:Magnetic Resonance Imaging; D008297:Male; D017590:Myelinolysis, Central Pontine / Q000209:etiology / Q000378:metabolism* / Q000473:pathology; D009997:Osmotic Pressure
chemical_list: D050034:Antidiuretic Agents; D003894:Deamino Arginine Vasopressin