Figure 122

Hyponatremic patients at risk for neurologic complications. Those at risk for cerebral edema include postoperative menstruant women, elderly women taking thiazide diuretics, children, psychiatric patients with polydipsia, and hypoxic patients. In women, and, in particular, menstruant ones, the risk for developing neurologic complications is 25 times greater than that for nonmenstruant women or men. The increased risk was independent of the rate of development, or the magnitude of the hyponatremia [21]. The osmotic demyelination syndrome or central pontine myelinolysis seems to occur when there is rapid correction of low osmolality (hyponatremia) in a brain already chronically adapted (more than 72 to 96 hours). It is rarely seen in patients with a serum sodium value greater than 120 mEq/L or in those who have hyponatremia of less than 48 hours' duration [20,21]. (Adapted from Lauriat and Berl [21]; with permission.)

Initial symptoms

Mutism Dysarthria

Lethargy and affective changes

Classic symptoms

Spastic quadriparesis Pseudobulbar palsy

Lesions in the midbrain, medulla oblongata, and pontine tegmentum

Pupillary and oculomotor abnormalities Altered sensorium Cranial neuropathies Extrapontine myelinolysis Ataxia

Behavioral abnormalities

Parkinsonism

Dystonia

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