Letter to the Editor
Reversible delayed post-hypoxic leukoencephalopathy
Leucoencefalopatía posthipóxica diferida reversible
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The adaptive response hypothesis proposes that Aβ can accumulate as an adaptive response to chronic stress stimuli such as metabolic dysregulation (altered cholesterol homeostasis or insulin resistance). According to this hypothesis, treatment would consist of drugs that restore insulin tolerance. The right drug treatment for slowing AD would act on these stress stimuli (the inflammatory response, mitochondrial changes, etc.).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Folch, M. Ettcheto, D. Petrov, S. Abad, I. Pedrós, M. Marin, J. Olloquequi, A. Camins" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Folch" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ettcheto" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Petrov" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Abad" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Pedrós" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Marin" ] 6 => array:2 [ "nombre" => "J." 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Tainta, P. de la Riva, M.Á. Urtasun, J.F. Martí-Massó" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Tainta" "email" => array:1 [ 0 => "mikeltainta@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "de la Riva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.Á." "apellidos" => "Urtasun" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.F." "apellidos" => "Martí-Massó" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad País Vasco, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Área de Neurociencias, Instituto Biodonostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leucoencefalopatía posthipóxica diferida reversible" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2418 "Ancho" => 2500 "Tamanyo" => 277096 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial MRI images obtained 3 weeks after the hypoxic event, with restricted diffusion in the diffusion-weighted sequence (A) and hyperintensity in the T2-weighted sequence (B) extensively affecting the whole periventricular white matter. Below, diffusion-weighted (C) and T2-weighted sequences (D) obtained one year later show the resolution of both alterations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Delayed post-hypoxic leukoencephalopathy (DPHL) is a rare condition that may manifest after a prolonged period of cerebral hypoxia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 43-year-old man who was found unconscious at his home. Examination revealed generalised muscle rigidity, miotic pupils, lack of response to stimuli, and a Glasgow Coma Scale score of 3. He initially responded to intravenous naloxone, but significant respiratory effort persisted, with tachypnoea, tachycardia, and diffuse rhonchi on auscultation. Despite receiving oxygen at an FiO<span class="elsevierStyleInf">2</span> of 100%, and nebulised salbutamol and ipratropium bromide, the patient developed acute respiratory failure, requiring orotracheal intubation and mechanical ventilation. He presented low-grade fever, and a chest radiography revealed consolidations at both lung bases; the results of a cranial CT scan and a blood test were normal. A urine test revealed presence of benzodiazepines, opioids, and cannabis. His personal history included paranoid schizophrenia, beginning in adolescence and treated with olanzapine and amisulpride. He also occasionally consumed opioid and sedative drugs, cannabis, and cocaine.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Two days after admission, his level of consciousness recovered; a neurological examination yielded normal results. As a complication, the patient developed a respiratory infection, which responded well to antibiotics, and acute renal damage secondary to an increased level of creatine kinase (8277<span class="elsevierStyleHsp" style=""></span>U/L), due to probable rhabdomyolysis. Twenty-one days after admission, his condition suddenly worsened, with the development of somnolence and bradypsychia. He progressively began to present stereotypic movements, motor disinhibition, and reduced verbal communication, with diminished fluency and impaired comprehension. All limbs presented cogwheel rigidity. Myotatic reflexes were normal and plantar reflexes were flexor bilaterally. No focal deficit in strength or sensitivity was observed at any time. He became unable to walk, as gait deteriorated with a significant apraxic component. In the following days, clinical symptoms deteriorated until the patient's condition progressed to akinetic mutism.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A brain magnetic resonance imaging (MRI) scan performed 3 weeks after the hypoxic event revealed extensive involvement of the white matter in T2-weighted and FLAIR sequences, and restriction in diffusion-weighted sequences (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">General analysis including a coagulation study, autoimmunity study, serology test, copper test, lactate tests, and arylsulphatase A test yielded no relevant findings. The patient received general care and rehabilitation therapy and his condition improved gradually; after 2 months and a half, he had recovered to a baseline state and was discharged. One year after admission, the patient remains asymptomatic and can perform the activities of daily living independently. Likewise, MRI scans show a very favourable evolution (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C and D). Considering the clinical and radiological recovery, and having excluded other possible inflammatory or infectious causes, final diagnosis was reversible DPHL.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This condition is typically characterised by a biphasic course with an immediate recovery after an episode of cerebral hypoxia-induced coma; onset is followed by neuropsychiatric symptoms days or weeks after the episode.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The cause most frequently associated with this entity is carbon monoxide poisoning,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> but it may also occur after other such anoxic events as strangulation,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> haemorrhagic shock,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4,5</span></a> or opiate or sedative agent abuse,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">6,7</span></a> as in our case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The precise pathophysiological mechanism of DPHL is still to be determined, but given the similarity between the demyelinating findings on the MRI and those typical of metachromatic leukodystrophy, it has been suggested that a deficiency of arylsulphatase A (which is necessary for myelin turnover) may predispose to this syndrome.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8,9</span></a> However, several similar cases with normal levels of this enzyme have also been published.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> Other mechanisms involved are the myelin toxicity of some external agents,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> alterations in the regulation of white matter vascularisation,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> or the specific susceptibility of white matter oligodendrocytes to cerebral hypoxia.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The characteristic clinical symptoms include cognitive/behavioural impairment, disorientation, frontal signs, amnesia, parkinsonism, akinetic mutism, and psychosis. MRI images typically show hyperintensity in T2- and diffusion-weighted sequences; cerebrospinal fluid analysis yields normal results. There is no specific treatment, and prognosis may vary; complete recovery may be achieved, probably depending on the patient's age.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, DPHL is an infrequent entity with characteristic clinical symptoms which should be known in order to avoid administering unnecessary treatments and diagnostic tests; cranial MRI scans are useful for diagnosis and follow-up.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This study received no funding of any kind.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tainta M, de la Riva P, Urtasun MÁ, Martí-Massó JF. Leucoencefalopatía posthipóxica diferida reversible. Neurología. 2018;33:59–61.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2418 "Ancho" => 2500 "Tamanyo" => 277096 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial MRI images obtained 3 weeks after the hypoxic event, with restricted diffusion in the diffusion-weighted sequence (A) and hyperintensity in the T2-weighted sequence (B) extensively affecting the whole periventricular white matter. Below, diffusion-weighted (C) and T2-weighted sequences (D) obtained one year later show the resolution of both alterations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The syndrome of delayed post-hypoxic leukoencephalopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Shprecher" 1 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 0 | 8 |
| 2024 October | 36 | 3 | 39 |
| 2024 September | 79 | 17 | 96 |
| 2024 August | 52 | 8 | 60 |
| 2024 July | 77 | 7 | 84 |
| 2024 June | 60 | 6 | 66 |
| 2024 May | 49 | 9 | 58 |
| 2024 April | 73 | 8 | 81 |
| 2024 March | 78 | 12 | 90 |
| 2024 February | 69 | 9 | 78 |
| 2024 January | 128 | 4 | 132 |
| 2023 December | 86 | 12 | 98 |
| 2023 November | 100 | 17 | 117 |
| 2023 October | 115 | 12 | 127 |
| 2023 September | 113 | 12 | 125 |
| 2023 August | 94 | 12 | 106 |
| 2023 July | 93 | 1 | 94 |
| 2023 June | 79 | 5 | 84 |
| 2023 May | 108 | 15 | 123 |
| 2023 April | 74 | 3 | 77 |
| 2023 March | 90 | 8 | 98 |
| 2023 February | 84 | 3 | 87 |
| 2023 January | 96 | 11 | 107 |
| 2022 December | 121 | 9 | 130 |
| 2022 November | 101 | 8 | 109 |
| 2022 October | 89 | 5 | 94 |
| 2022 September | 119 | 9 | 128 |
| 2022 August | 116 | 10 | 126 |
| 2022 July | 69 | 13 | 82 |
| 2022 June | 64 | 14 | 78 |
| 2022 May | 81 | 10 | 91 |
| 2022 April | 88 | 9 | 97 |
| 2022 March | 126 | 11 | 137 |
| 2022 February | 126 | 9 | 135 |
| 2022 January | 99 | 6 | 105 |
| 2021 December | 106 | 10 | 116 |
| 2021 November | 108 | 24 | 132 |
| 2021 October | 90 | 15 | 105 |
| 2021 September | 63 | 15 | 78 |
| 2021 August | 74 | 11 | 85 |
| 2021 July | 71 | 12 | 83 |
| 2021 June | 73 | 11 | 84 |
| 2021 May | 109 | 12 | 121 |
| 2021 April | 136 | 12 | 148 |
| 2021 March | 133 | 10 | 143 |
| 2021 February | 70 | 11 | 81 |
| 2021 January | 84 | 15 | 99 |
| 2020 December | 75 | 6 | 81 |
| 2020 November | 77 | 19 | 96 |
| 2020 October | 50 | 8 | 58 |
| 2020 September | 54 | 9 | 63 |
| 2020 August | 91 | 10 | 101 |
| 2020 July | 103 | 18 | 121 |
| 2020 June | 79 | 21 | 100 |
| 2020 May | 82 | 22 | 104 |
| 2020 April | 163 | 12 | 175 |
| 2020 March | 37 | 13 | 50 |
| 2020 February | 60 | 17 | 77 |
| 2020 January | 54 | 12 | 66 |
| 2019 December | 60 | 10 | 70 |
| 2019 November | 30 | 5 | 35 |
| 2019 October | 55 | 13 | 68 |
| 2019 September | 33 | 11 | 44 |
| 2019 August | 40 | 15 | 55 |
| 2019 July | 49 | 22 | 71 |
| 2019 June | 94 | 14 | 108 |
| 2019 May | 258 | 27 | 285 |
| 2019 April | 111 | 31 | 142 |
| 2019 March | 16 | 6 | 22 |
| 2019 February | 55 | 12 | 67 |
| 2019 January | 24 | 8 | 32 |
| 2018 December | 14 | 5 | 19 |
| 2018 November | 15 | 4 | 19 |
| 2018 October | 46 | 13 | 59 |
| 2018 September | 44 | 5 | 49 |
| 2018 August | 17 | 2 | 19 |
| 2018 July | 9 | 2 | 11 |
| 2018 June | 7 | 1 | 8 |
| 2018 May | 18 | 2 | 20 |
| 2018 April | 21 | 5 | 26 |
| 2018 March | 8 | 2 | 10 |
| 2018 February | 2 | 0 | 2 |
| 2018 January | 3 | 7 | 10 |
| 2017 December | 1 | 4 | 5 |
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