Diagnostic Approach for Central Pontine Myelinolysis

Clinical Presentation and Diagnosis

• The American Academy of Neurology suggests that cranial nerve function, particularly nerves V-VIII which traverse the pons, should be assessed in patients with suspected Central Pontine Myelinolysis 1, 3
• Pontine gliomas can mimic Central Pontine Myelinolysis on imaging, and distinction is critical as management and prognosis differ significantly 1
• The presence of extrapontine involvement, such as basal ganglia, thalamus, or cerebellum, may occur concurrently with Central Pontine Myelinolysis 1
• The European Federation of Neurological Societies recommends considering Progressive Multifocal Leukoencephalopathy (PML) in the differential diagnosis, characterized by subacute onset, diffuse lesions, typically in immunocompromised patients 2

Imaging Characteristics

• The International Society for Magnetic Resonance in Medicine suggests that MRI brain is the diagnostic test of choice for Central Pontine Myelinolysis, and T2-weighted and FLAIR sequences demonstrate characteristic hyperintensity in the central pons 1
• CT limitations include initial CT being completely normal and missing small pontine lesions in up to 25% of cases 1
• Contrast enhancement is typically not present in Central Pontine Myelinolysis, which helps differentiate it from pontine tuberculoma 1