Post-partum hypernatremic osmotic demyelination

Case contributed by Vinay V Belaval
Diagnosis certain


Slurring of speech and altered sensorium of 1-day duration. Lower segment cesarian section (LSCS) 10 days ago.

Patient Data

Age: 25 years
Gender: Female

Axial DWI (diffusion-weighted image) and corresponding ADC (apparent diffusion coefficient) images of the brain show symmetrical areas of restricted diffusion involving posterior limbs of both internal capsules and anterolateral midbrain along the corticospinal tracts. These changes are apparent on axial T2 imaging in the form of T2 hyperintense signals. Restricted diffusion is also seen in splenium of corpus callosum. Subtle hypointense signals are seen in the affected regions on T1w axial image.

These imaging findings, along with an acute clinical presentation, a history of recent LSCS and high serum sodium levels, are consistent with post-partum hypernatremic osmotic demyelination.

Case Discussion

Young woman with recent history of LSCS presented with slurred speech and altered sensorium of one-day duration. 

MRI brain done showed symmetrical areas of T2 and FLAIR hyperintensities with restricted diffusion along corticospinal tracts in posterior limbs of internal capsules and anterolateral midbrain and also in the splenium of corpus callosum. The possibility of post-partum hypernatremic osmotic demyelination was raised. It was confirmed by high serum sodium levels and the patient was treated conservatively. The patient recovered well.

Acute neurological emergencies in post-partum period can be due to a variety of causes including cerebral venous sinus thrombosis (CVT), posterior reversible encephalopathy syndrome (PRES) and various metabolic abnormalities.

Post-partum hypernatremic osmotic demyelination is a rare dyselectrolytemia presenting with acute encephalopathy.

MRI is the imaging modality of choice and reveals symmetrical areas of T2 and FLAIR hyperintensities with restricted diffusion along the corticospinal tracts and typically, in the splenium of corpus callosum.

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