Appropriate Consultation for Suspected Central Pontine Myelinolysis
Patients with suspected central pontine myelinolysis should be referred to a neurologist for evaluation and management.
Primary Consultation
Neurology consultation is the appropriate first-line referral for suspected central pontine myelinolysis (CPM), as this is an acute demyelinating neurological disorder requiring specialized neurological assessment and management 1, 2.
The neurologist should evaluate for the characteristic clinical features including progressive neurologic deficits, spastic quadriparesis, dysarthria, pseudobulbar palsy, encephalopathy, or in severe cases, "locked-in" syndrome 1, 2.
Neuropsychiatric manifestations such as acute psychosis, personality changes, paranoia, or hallucinations may be the primary presentation, particularly in early stages, and still warrant neurological evaluation 2.
Timing of Referral
Urgent neurological consultation is indicated given that CPM can progress rapidly to severe disability or death, and early diagnosis with treatment might reverse an otherwise malignant syndrome 1.
The urgency should be within 48 hours if the patient requires assistance with self-care, or emergency admission if unable to care for themselves without help, following general principles for acute neurological conditions 3.
Key Clinical Context for Consultation
The neurologist should be informed of:
Electrolyte disturbances, particularly hyponatremia and the rate of correction, as rapid correction is the most common precipitating factor 1, 2, 4.
History of alcohol abuse, chronic debilitation, or other risk factors 1.
Hyperglycemic hyperosmolar states or rapid changes in osmolality, as CPM can occur with hyperglycemia even without hyponatremia 5, 6.
Timeline of symptom onset relative to electrolyte correction, as this helps establish the diagnosis 1, 4.
Diagnostic Imaging Considerations
MRI with diffusion-weighted imaging (DWI) is the diagnostic modality of choice and should be arranged urgently through the neurologist, as DWI can identify restricted diffusion in the central pons within 24 hours of symptom onset, before conventional MRI sequences show abnormalities 4.
Initial MRI may be unremarkable in early stages, and repeat imaging 1-2 weeks later may be necessary to demonstrate characteristic pontine changes 2.
Common Pitfalls to Avoid
Do not delay neurological consultation waiting for MRI confirmation, as imaging findings lag behind clinical manifestations and early intervention may be critical 1, 4.
Do not assume CPM is excluded based on normal initial brain imaging, particularly in the first 24-48 hours after symptom onset 2, 4.
Recognize that isolated neuropsychiatric symptoms or isolated hemiplegia without classic pontine signs can be the presenting manifestation of CPM 2, 6.