JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
PATIENT MANAGEMENT
In cases where early MRI studies performed 1-6 days after the onset of ODS symptoms were normal, corresponding brain lesions were shown to develop on repeat MRI 1-2 weeks later. 18 In a retrospective case series correlating MRI findings with clinical outcomes of patients with CPM, the value of serial brain imaging in suspected cases of ODS was emphasized, as a significant proportion of patients with ODS were found to have no abnormalities on initial MRI studies. 19
Management of ODS starts and ends with prevention. ODS occurs most often in patients with observed serum sodium concentrations <120 mmol/L for greater than 48 hours. Current expert guidelines recommend limiting correction of chronic hyponatremia to <10 to 12 mmol/L in 24 hours and to <18 mmol/L in 48 hours.20 Metabolic derangements in patients with liver disease may increase susceptibility to ODS. Wilson’s disease, alpha-1-antitrypsin deficiency, and non-alcoholic steatohepatitis have been identified in the literature to date. 10,11 It may be worthwhile to slow the rate of sodium replacement even further in these patients. However, if symptoms attributable to hyponatremia do not resolve, physicians must weigh them against the risk of ODS. 2 If a patient’s sodium level has increased too rapidly, one may use hypotonic saline or desmopressin to slow sodium replacement rate or even reduce plasma sodium level. 21 Once ODS has developed, there is no proven treatment outside supportive care. Such care consists of minimizing secondary complications of neurological impairment, including aspiration pneumonia, ascending urinary tract infections, venous thrombosis, and pulmonary embolism. One case series of 44 patients showed that permanent outcomes were not tightly correlated to neurological symptoms in the acute phase. 22 Clinicians may consider discontinuing neurotoxic medications, though data regarding their interplay with ODS is insufficient. 11 Recent publications discuss the role of steroid administration prior to rapid correction of hyponatremia, as well as the use of minocycline and other anti-apoptotic drugs. 12 Studies in rats have shown that steroids have a protective effect and may speed recovery, though there are no clinical trials in humans to support this practice. 23 This intervention deserves further study.
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PROGNOSIS
Classically ODS was considered to have a very poor prognosis, earlyonbeingapost-mortemdiagnosisonlyidentifieduponbrain autopsy. With the increased knowledge of the pathophysiology of ODS, and the advent of MRI, primary prevention and early diagnosis have significantly improved the disease outcome. Most patients survive if there are no serious complications like aspiration, sepsis or pulmonary thromboembolism. 24 In a recent cohort study examining clinical outcomes and factors predictive of prognosis in ODS, it was concluded that almost half of the patients who develop ODS make a meaningful clinical and functional recovery. 18 There is a case report by W El Mogahazy et al. describing a patient’s recovery from a locked-in state to ambulation with aid, fluid speech, and swallowing. 11 Despite improved overall outcomes, there has been little success in defining prognostic factors for ODS. Notably, studies have shown that although MRI is key in diagnosing ODS, the size of the lesion on MRI cannot be directly correlated with the clinical outcome. In a retrospective case series by J Radford et al., MRI
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Figure 2. MR non-enhanced of a 52-year-old man with a history of chronic alcoholism and chronic liver disease, who presented with ataxia and confusion. (A) Axial T2 image revealing hyperintense signal involving the pons and cerebellar peduncles. (B) Axial Flair image revealing hyperintense signal within the pons. (C) Sagittal T1 image revealing hyperintense signal in the pons. (D, E, F) Axial Flair images revealing hyperintense signal involving the peri-ventricular area, pons, and superior cerebellum, and vermis.
J La State Med Soc VOL 169 JULY/AUGUST 2017 91
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