Central pontine myelinolysis and perioperative hyponatremia: particularities in liver transplant surgery.
DOI:
https://doi.org/10.35954/SM2013.32.1.6Keywords:
Anesthesia; Demyelination; Hyponatremia; Central Pontine Myelinolysis; Intensive Care.Abstract
Central pontine myelinolysis (CPM) or central pontine myelinolysis (CPM) is a rare neurological disease that can lead to severe and permanent neurological sequelae or even death. It causes demyelination of the pons and in 10% of patients affects extrapontine areas and is known as osmotic demyelination syndrome or extra pontine demyelination (EPD). Cirrhotic patients and those undergoing liver transplantation are at high risk of developing PCM and SPD. Its most frequent cause is the rapid and inadequate correction of hyponatremia but it can also occur with normal or even increased basal serum sodium. Intraoperatively in major surgeries (such as liver transplantation), blood loss may require the administration of several liters of solutions with normal osmolarity. If the patient has preoperative hyponatremia, a sharp increase in plasma sodium is generated, which may cause MCP. However, there are other sodium-independent factors that can produce this condition that will also be discussed in this review.
Downloads
Metrics
References
(1) Adams RD, Victor M, Mancall EL. Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholic and malnourished patients. Arch Neurol Psychiatr 1959; 81(2):154-72.
(2) Cartier RL, Armijo MJ, Quiroz ZG, Matamala CJ. Mielinolisis central pontina en trasplante hepatico. Rev Méd Chile 2010; 138(10):1264-71.
(3) Love S. Demyelinating diseases. J Clin Pathol 2006; 59(11):1151-9.
(4) Musana AK, Yale SH. Central pontine myelinolysis: case series and review. WMJ 2005; 104(6):56-60.
(5) Tatewaki Y, Kato K, Tanabe Y, Takahashi S. MRI findings of corticosubcortical lesions in osmotic myelinolysis: report of two cases. Br J Radiol 2012; 85(1012):e87-90.
(6) Lampl C, Yazdi K. Central pontine myelinolysis. Eur Neurol 2002; 47(1):3-10.
(7) Morais BS, Carneiro FS, Araujo RdM, Araujo GF, Oliveira RB. Central pontine myelinolysis after liver transplantation: is sodium the only villain? Case report. Rev Bras Anestesiol 2009; 59(3):344-9.
(8) Imam YZ, Saqqur M, Alhail H, Deleu D. Extrapontine myelinolysis-induced parkinsonism in a patient with adrenal crisis. Case reports in neurological medicine 2012; 2012:327058:3 p. Disponible en: http://dx.doi.org/10.1155/2012/327058 [Consulta 25/01/2013]
(9) Abbasoglu O, Goldstein RM, Vodapally MS, Jennings LW, Levy MF, Husberg BS, et al. Liver transplantation in hyponatremic patients with emphasis on central pontine myelinolysis. Clin Transplant 1998; 12(3):263-9.
(10) Yun BC, Kim WR, Benson JT, Biggins SW, Therneau TM, Kremers WK, et al. Impact of pretransplant hyponatremia on outcome following liver transplantation. Hepatology (Baltim.) 2009; 49(5):1610-5.
(11) Sterns RH, Silver S, Kleinschmidt-DeMasters BK, Rojiani AM. Current perspectives in the management of hyponatremia: prevention of CPM. Expert review of neurotherapeutics 2007; 7(12):1791-7.
(12) Yamada H, Takano K, Ayuzawa N, Seki G, Fujita T. Relowering of serum na for osmotic demyelinating syndrome. Case reports in neurological medicine 2012:704639 Disponible en: http://pubmedcentralcanada.ca/pmcc/articles/PMC3420698/ [Consulta 01/09/2012].
(13) Al-Sarraf AJ, Haque M, Pudek M, Yoshida EM. Central pontine myelinolysis after orthotopic liver transplant-a rare complication. Exp Clin Transplant 2010; 8(4):321-4.
(14) Rizzo MA, Frediani F, Granata A, Ravasi B, Cusi D, Gallieni M. Neurological complications of hemodialysis: state of the art. J Nephrol 2012; 25(2):170-82.
(15) Mzabi A, Ben Fredj Ismail F, Hasni I, Mrad B, Karmani M, Laouani Kechrid C. Central pontine myelinolysis. La Tunisie Med 2012; 90(11):832-3.
(16) Hegazi MO, Mashankar A. Central pontine myelinolysis in the hyperosmolar hyperglycaemic state. Med Princ Pract 2013; 22(1):96-9.
(17) Levin J, Hogen T, Patzig M, Pfister HW, Peters N. Pontine and extrapontine myolinolysis associated with hypernatraemia. Clin Neurol Neurosurg 2012; 114(9):1290-1.
(18) Rego I, Vieira D, Correia F, Pereira JR. Multiple brain lesions in a young man with hypernatraemia. BMJ case reports 2012; 10.1136/bcr.11.2011.5198. Disponible en: http://casereports.bmj.com/content/2012/bcr.11.2011.5198.full.pdf+html [Consulta 19/05/2012].
(19) Gupta R, Balhara YP, Sagar R. Acute psychosis with a favorable outcome as a complication of central pontine/extrapontine myelinolysis in a middle aged man. J Midlife Health 2012; 3(2):103-5.
(20) Schneider P, Nejtek VA, Hurd CL. A case of mistaken identity: alcohol withdrawal, schizophrenia, or central pontine myelinolysis? Neuropsychiatr Dis Treat 2012; 8:49-54.
(21) Kishimoto Y, Ikeda K, Murata K, Kawabe K, Hirayama T, Iwasaki Y. Rapid development of central pontine myelinolysis after recovery from Wernicke encephalopathy: a non-alcoholic case without hyponatremia. Intern Med (Tokyo) 2012; 51(12):1599-603.
(22) 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(5):407-11.
(23) Odier C, Nguyen DK, Panisset M. Central pontine and extrapontine myelinolysis: from epileptic and other manifestations to cognitive prognosis. J Neurol 2010; 257(7):1176-80.
(24) Yu J, Zheng SS, Liang TB, Shen Y, Wang WL, Ke QH. Possible causes of central pontine myelinolysis after liver transplantation. World J Gastroenterol 2004; 10(17):2540-3.
(25) Lee EM, Kang JK, Yun SC, Kim KH, Kim SJ, Hwang KS, et al. Risk factors for central pontine and extrapontine myelinolysis following orthotopic liver transplantation. Eur Neurol 2009; 62(6):362-8.
(26) Fryer JP, Fortier MV, Metrakos P, Verran DJ, Asfar SK, Pelz DM, et al. Central pontine myelinolysis and cyclosporine neurotoxicity following liver transplantation. Transplantation 1996; 61(4):658-61.
(27) Kabeer MH, Filo RS, Milgrom ML, Pescovitz MD, Leapman SB, Lumeng L, et al. Central pontine myelinolysis following orthotopic liver transplant: association with cyclosporine toxicity. Postgrad Med J 1995; 71(834):239-41.
(28) Vizzini G, Asaro M, Miraglia R, Gruttadauria S, Fili D, D'Antoni A, et al. Changing picture of central nervous system complications in liver transplant recipients. Liver transpl 2011; 17(11):1279-85.
(29) Fukazawa K, Nishida S, Aguina L, Pretto E, Jr. Central pontine myelinolysis (CPM) associated with tacrolimus (FK506) after liver transplantation. Ann Transplant 2011; 16(3):139-42.
(30) Rodriguez J, Benito-Leon J, Molina JA, Ramos A, Bermejo F. Mielinolisis central pontina asociada a ciclosporina en el trasplante hepatico. Neurologia 1998; 13(9):437-40.
(31) Mata Tapia I, Galan Cabezas A, Lluch Fernandez M. Mielinolisis central pontina en el contexto de un trasplante hepatico reducido. Rev Esp Anestesiol Reanim 2010; 57(9):606-7.
(32) Norenberg MD. A hypothesis of osmotic endothelial injury. A pathogenetic mechanism in central pontine myelinolysis. Arch Neurol 1983; 40(2):66-9.
(33) Starzl TE, Schneck SA, Mazzoni G, Aldrete JA, Porter KA, Schroter GP, et al. Acute neurological complications after liver transplantation with particular reference to intraoperative cerebral air embolus. Ann Surg 1978; 187(3):236-40.
(34) Yilmaz M, Cengiz M, Sanli S, Yegin A, Mesci A, Dinckan A, et al. Neurological complications after liver transplantation. J Int Med Res 2011; 39(4):1483-9.
(35) El Moghazy W, Gala-Lopez B, Wong W, Kneteman N. Recovery of locked-in syndrome following liver transplantation with calcineurin inhibitor cessation and supportive treatment. Am J Case Rep 2013; 14:16-9.
(36) Mellado P, Peredo P, Valenzuela R, Arrese M, Perez RM, Dominguez P, et al. Complicaciones neurologicas en pacientes adultos sometidos a trasplante hepatico ortotopico: experiencia de un centro universitario. Rev méd Chile 2008; 136(10):1255-63.
(37) Buis CI, Wijdicks EF. Serial magnetic resonance imaging of central pontine myelinolysis. Liver transpl 2002; 8(7):643-5.
(38) Jiang Y, Wei JJ, Wang RZ, Ren ZY. [Osmotic demyelination syndrome in patients with hyponatremia caused by neurologic disorders]. Zhongguo yi xue ke xue yuan xue bao=Acta Academiae Medicinae Sinicae 2011;33(6):696-700.
(39) Brito AR, Vasconcelos MM, Cruz Junior LC, Oliveira ME, Azevedo AR, Rocha LG, et al. Central pontine and extrapontine myelinolysis: report of a case with a tragic outcome. J Pediatr 2006; 82(2):157-60.
(40) Sutamnartpong P, Muengtaweepongsa S, Kulkantrakorn K. Wernicke's encephalopathy and central pontine myelinolysis in hyperemesis gravidarum. J Neurosci Rural Pract 2013; 4(1):39-41.
(41) Min Y, Park SH, Hwang SB. Corticospinal tract and pontocerebellar fiber of central pontine myelinolysis. Ann Rehabil Med 2012; 36(6):887-92.
(42) de Souza A, Desai PK. More often striatal myelinolysis than pontine? A consecutive series of patients with osmotic demyelination syndrome. Neurol Res 2012; 34(3):262-7.
(43) Armand JP, Dousset V, Winnock S, Viaud B, Berge J, Caille JM. [Diagnosis of extrapontine myelinolysis preceding central pontine myelinolysis]. J Radiol 1995; 76(8):521-3.
(44) Hitoshi S, Terao Y, Mizuno T, Takeda K, Sakuta M. [A case of portal-systemic encephalopathy presenting characteristic MR images in globus pallidus, hypothalamus, corpus callosum, pontine base, and middle cerebellar peduncle]. Rinsho shinkeigaku = Clinical neurology 1992; 32(2):217-9.
(45) Saner FH, Koeppen S, Meyer M, Kohnle M, Herget-Rosenthal S, Sotiropoulos GC, et al. Treatment of central pontine myelinolysis with plasmapheresis and immunoglobulins in liver transplant patient. Transplant Int 2008; 21(4):390-1.
Published
How to Cite
Issue
Section
License
Until 2024 we use the Creative Commons Attribution/NonCommercial Attribution 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/deed.es. Which states that: you are free to share, copy and redistribute the material in any medium or format, as well as to adapt, remix, transform and build upon the material. Under the following terms:
Attribution: you must give proper credit , provide a link to the license, and indicate if changes have been made . You may do so in any reasonable manner, but not in such a way as to suggest that you or your use is endorsed by the licensor.
NonCommercial: you may not use the material for commercial purposes.
As of 2025 authors retain their copyright and assign to the journal the right of first publication of their work, which shall simultaneously be subject to the license https://creativecommons.org/licenses/by-nc-sa/4.0/deed.es that permits sharing, copying and redistribution of the material in any medium or format provided that initial publication in this journal is indicated. Adapt, remix, transform and build upon the material. If you remix, transform, or build from the material, you must distribute your contribution under the same license as the original and may not make use of the material for commercial purposes.
Under the following terms:
1. Attribution: you must give proper credit, provide a link to the license, and indicate whether changes have been made. You may do so in any reasonable manner, but not in such a way as to suggest that you or your use is endorsed by the licensor.
2. NonCommercial: you may not use the material for commercial purposes.
3. ShareAlike: if you remix, transform or build upon the material, you must distribute your contribution under the same license as the original.
PlumX Metrics
/
