Osmotic cerebral edema

Case contributed by Yahya Baba


Hypertrophic pyloric stenosis treated with pyloroplasty two days ago. Presents with status epilepticus and anisocoria. Hypernatremia (210 mmol/L) on biochemical tests.

Patient Data

Age: 33 days
Gender: Male

Initial CT - Day 01

  • there are hypodensities involving the pons and the midbrain with ill-defined hypodensity of the basal ganglia

  • bilateral benign enlargement of the subarachnoid space in infancy

The CT features were suggestive of an osmotic demyelination syndrome.

The infant went on a 48h-hypernatremia correction protocol.

Day 03

  • onset of diffuse cerebral edema with effacement of the sulci and cisterns and marked loss of grey-white differentiation

  • bilateral tonsillar herniation

  • onset of a mild subcutaneous edema

  • white cerebellum sign

There was no decompressive craniectomy indication for this infant according to neurosurgeons, considering the severe alteration of the neurologic exam.

Day 05


This brain CTA was performed to help confirm brain death

  • increased cerebral and subcutaneous edema

  • slightly reduced opacification of intracranial vasculature due to raised intracranial pressure.

  • opacification of the internal carotid arteries and reduced opacification of M2 segments. Bilateral minimal vascular opacification beyond this point

  • the basilar and vertebral arteries are unremarkable

Case Discussion

This case demonstrates a severe osmotic cerebral edema and white cerebellum sign, due to a probable rapid hypernatremia correction.

The CTA was non-conclusive, and brain death was confirmed five days after the initial CT, based on the clinical exams.

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