Hyponatremia and Central Pontine Myelinolysis

What is hyponatremia? Information regarding CPM and EPM.

What’s the difference (types of brain injury and their symptoms):

There seems to be a belief that “how” you get an injury makes a difference as to what symptoms you may or may not experience.

If you have a bacterial infection that destroys your heart tissue and that leads to a heart attack, is that different than having clogged arteries that lead to a heart attack?  Of course, there are some differences, the how you had a heart attack, but once the damage is done, the outcome is the same; your heart has been damaged. You will have to live with the damage and its impact to your heart and body.

There is a belief among doctors that brain injuries are universally different depending on how your brain was injured. There is a belief that if you were hit in the head or suffered a concussion, the injury to the brain will not produce the same symptoms as when you have a stroke or an injury due to a chemical imbalance.

I’ve discussed previously that the injury to the brain itself might be a static injury. For instance, once you’ve been in a car accident, your brain will not continue to receive  injury from the car accident itself, but there is  new research that shows that symptoms continue to persist and develop due to the body’s autoimmune response.

There are several ways that a person can get a brain injury.  According to Ohio State University Medical Center, the following is a list of brain injuries and how they differ:

  • Concussion
    A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event.
  • Skull fracture
    A skull fracture is a break in the skull bone. There are four major types of skull fractures, including the following:

    Illustration of different types of skull fractures
    Click Image to Enlarge
    • Linear skull fractures
      This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but it does not move the bone. These patients may be observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. Usually, no interventions are necessary.
    • Depressed skull fractures
      This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on the severity, to help correct the deformity.
    • Diastatic skull fractures
      These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse when we are children. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and older infants.
    • Basilar skull fracture
      This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These patients usually require close observation in the hospital.
    • Intracranial hematoma (ICH)
      There are several types of ICH, or blood clots, in or around the brain. The different types are classified by their location in the brain. These can range from mild head injuriesto quite serious and potentially life-threatening injuries. The different types of ICH include the following:

      Illustration of Intracranial Hematoma
      Click Image to Enlarge
      • Epidural hematoma
        Epidural hematomas occur when a blood clot forms underneath the skull, but on top of the dura, the tough covering that surrounds the brain. They usually come from a tear in an artery that runs just under the skull called the middle meningeal artery. Epidural hematomas are usually associated with a skull fracture.
      • Subdural hematoma
        Subdural hematomas occur when a blood clot forms underneath the skull and underneath the dura, but outside of the brain. These can form from a tear in the veins that go from the brain to the dura, or from a cut on the brain itself. They are sometimes, but not always, associated with a skull fracture.
      • Contusion or intracerebral hematoma
        A contusion is a bruise to the brain itself. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck. Contusions may occur with skull fractures or other blood clots such as a subdural or epidural hematoma. When bleeding occurs inside the brain itself (also called “intraparenchymal hemmorage”), this can sometimes occur spontaneously. When trauma is not the cause, the most common causes are long-standing high blood pressure in older adults, bleeding disorders in either children or adults, or the use of medications that cause blood thinning or certain drugs of abuse.
      • Diffuse axonal injury (DAI)
        These injuries are fairly common and are usually caused by shaking of the brain back and forth, which can happen in car accidents, from falls or shaken baby syndrome. Diffuse injuries can be mild, such as with a concussion, or may be very severe, as in diffuse axonal injury (DAI). In DAI, the patient is usually in a coma for a prolonged period of time, with injury to many different parts of the brain. (http://medicalcenter.osu.edu/patientcare/healthcare_services/nervous_system/injury/Pages/index.aspx)

Notice in the above list, it does not mention brain injuries caused by stroke. It does not mention injuries caused by infection, like meningitis. It does not mention injury caused from Central Pontine Myelinolysis. It does not mention injury caused by disease, like Multiple Sclerosis.

If you read about any of the above diseases, injuries or disorders, you will find that those who experience injuries to the brain by any means, has similar symptoms.

Those who have MS experience movement issues:

    • Blurred or double vision
    • Red-green color distortion
    • Pain and loss of vision due to optic neuritis, an inflammation of the optic nerve
    • Difficulty walking
    • Paresthesia – abnormal sensation, or pain, such as numbness, prickling, or “pins and needles.”
  • Other symptoms of multiple sclerosis:
    Throughout the course of the illness, an individual may experience any/all of the following symptoms, to a varying degree:

    • Muscle weakness in the extremities
    • Difficulty with coordination (impaired walking or standing may result; partial or complete paralysis is possible)
    • Spasticity – the involuntary increased tone of muscles leading to stiffness and spasms.
    • Fatigue (this may be triggered by physical activity, but may subside with rest; constant, persistent fatigue is possible)
    • Loss of sensation
    • Speech impediments
    • Tremor
    • Dizziness
    • Hearing loss
    • Bowel and bladder disturbances
    • Depression
    • Changes in sexual function

The above list comes from, http://medicalcenter.osu.edu/patientcare/healthcare_services/nervous_system/ms/Pages/index.aspx

Stroke symptoms:

  • movement and sensation
  • speech and language
  • eating and swallowing
  • vision
  • cognitive (thinking, reasoning, judgment and memory) ability
  • perception and orientation to surroundings
  • self-care ability
  • bowel and bladder control
  • emotional control
  • sexual ability

In addition to these general effects, some specific impairments may occur when a particular area of the cerebrum is damaged.

Effects of a right hemisphere stroke:

The effects of a right hemisphere stroke may include the following:

  • left-sided weakness (left hemiparesis) or paralysis (left hemiplegia) and sensory impairment
  • denial of paralysis or impairment and reduced insight into the problems created by the stroke (this concept is called “left neglect”)
  • visual problems, including an inability to see the left visual field of each eye (homonymous hemianopsia)
  • spatial problems with depth perception or directions such as up/down and front/back
  • inability to localize or recognize body parts
  • inability to understand maps and find objects such as clothing or toiletry items
  • memory problems
  • behavioral changes such as lack of concern about situations, impulsivity, inappropriateness, and depression

Effects of a left hemisphere stroke:

The effects of a left hemisphere stroke may include the following:

  • right-sided weakness (right hemiparesis) or paralysis (right hemiplegia) and sensory impairment
  • problems with speech and understanding language (aphasia)
  • visual problems, including the inability to see the right visual field of each eye (homonymous hemianopsia)
  • impaired ability to do math or to organize, reason, and analyze items
  • behavioral changes such as depression, cautiousness, and hesitancy
  • impaired ability to read, write, and learn new information
  • memory problems

What effects can be seen with a stroke in the cerebellum?

The cerebellum is located beneath and behind the cerebrum towards the back of the skull. It receives sensory information from the body via the spinal cord and helps to coordinate muscle action and control, fine movement, coordination, and balance.

Although strokes are less common in the cerebellum area, the effects can be severe. Four common effects of strokes in the cerebellum include the following:

  • inability to walk and problems with coordination and balance (ataxia)
  • dizziness
  • headache
  • nausea
  • vomiting

What effects can be seen with a stroke in the brain stem?

The brain stem is located at the very base of the brain right above the spinal cord. Many of the body’s vital “life-support” functions such as heartbeat, blood pressure, and breathing are controlled by the brain stem. It also helps to control the main nerves involved with eye movement, hearing, speech, chewing, and swallowing. Some common effects of a stroke in the brain stem include problems with the following:

  • breathing and heart functions
  • body temperature control
  • balance and coordination
  • weakness or paralysis in all four limbs
  • chewing, swallowing, and speaking
  • vision
  • coma

The above information is taken from, http://medicalcenter.osu.edu/patientcare/healthcare_services/stroke/effects/Pages/index.aspx

The next list, is the list that I have found to be defining to those who have brain injuries in general. Notice how similar they are to what we find in things like stroke and MS:

Issues that are attributed to brain damage:

Hearing Issues (problems with understanding spoken word, tinnitus, dizziness, buzzing)
Visual Issues (blurry vision, color issues, blindness)
Heart Issues (problems with maintaining proper blood pressure and heart rates)
Cognitive Issues (memory deficits, learning issues, reading problems, writing problems, word recognition)
Hormone Issues (lack of Growth Hormone, sex hormones, hypothyroidism, and hypopituitarism)
Sexual Issues (lack of desire)
Reproductive Issues (lack of menses in women, lack of gonadotropin hormones)
Psychological Issues (depression, irritability, nervousness, anger, crying, anxiety)
Parkinson’s Disease
Alzheimer’s or Alzheimer’s like disease
Epilepsy (early to late onset of seizures, can occur up to 40 years after injury)
Sleep Disturbances (insomnia, inability to stay asleep, central nervous system sleep apnea)
Early Mortality (high risk of death during first 1 to 10 years after injury, after that life expectancy is 5-7 years less than average non injured person)
Incontinence (urinary or bowel)
Muscle Dysfunction (twitches, spams, jerks)
Mental Fatigue (difficulties working or going to school full time due to concentration deficits)
Speech disturbances (stutters, stammering, not being able to complete thoughts, not using proper words)
Issues with communicating
Movement disorders (problems with coordination, walking, standing, eating, tremors, shaking, swallowing, speaking)
Temperature control issues (too hot or too cold)
Complete paralysis (those with CPM/EPM are known to develop locked in syndrome)
Breathing issues (the brain forgets to tell the body to breathe, especially critical in sleep)
As you can see, people have very similar, if not identical symptoms, no matter how they received the brain damage. I am hopeful that over time doctors will come to realize that whether or not you were hit in the head or had a stroke the process and recupperation needs to be treated the same if not structured from the same basic model and tweaked to meet an individuals need.
Further, it needs to be understood that no matter HOW you got your injury, the immune system responds to the injury in the same manner leading to further complications as a person ages.
Now, I wanted to add some descriptions to the symptoms that you may experience with brain injuries. Iwas excited to find the following description of mental fatigue. I have experienced this as I returned back to work. I have had ongoing issues with this outside of work as well. I simply can not do as much as I did before. The mere act of trying to stay focused for long periods of time leaves me mentally and physically exhausted. My doctors first reaction when I explained this is that it must be a psychological phenomena related to knowing I have a brain injury. When a doctor gives these suggestions, you have to believe they must be right. It must be all in my head (ha-no pun intended). I was happy to find a research article discribing this issue as a part of having a brain injury.

Patients will recover within days to weeks, but a significant minority develop persistent mental fatigue, and it will take a long time before they can accept the situation and find
ways to lead their “new life”. Until then, life can be very mentally tiring and for many it can be a great strain. In the case of a slow recover, things might turn out not to work as smooth and easily as they used to. It is possible for patients to take walks in the forest, but reading, talking on the telephone or attending a meeting could be mentally very tiring and may require a prolonged rest afterwards. It is no longer a pleasure to go to parties, as they can’t take part in conversations, and they soon become extremely tired and want to go home. It might also be shameful for the person to admit that the brain does not work properly. They also tend to experience difficulties concentrating, and it could be difficult to filter what they hear and see. Every unimportant detail is registered. Sensitivity to stress is also very common, even in minor situations which they are normally able to handle.

http://cdn.intechopen.com/pdfs/30498/InTech-Mental_fatigue_a_common_long_term_consequence_after_a_brain_injury.pdf

I will try to include the additional research that I have found regarding brain injuries and what you can expect, no matter what type of injury you have.

Please keep in mind, no matter what type of injury you have, it does not mean that you will have all of these symptoms. It does not even mean that you will have life long consequences because of it. The severity of the injury, the location of the injury, and the initial treatment that you receive following the injury all determine the outcome that you will have following your injury. I believe fully that you can go on to lead a productive life depending on many factors that I will address later in the future.

 

UPDATE 11/14/12—I found this research article, which explains a significant number of the physical issues after a brain injury. It provides more of the physiological description of why the injury will cause the symptoms, like epilepsy, visual and auditory disturbances, cognitive dysfunctions.I was extremely happy that this article states that a person’s IQ remains relatively intact after these types of brain injuries (this is what I have experienced), but they continue to have issues with memory, learning, and retrieval.

http://jnnp.bmj.com/content/73/suppl_1/i8.full

Cognitive and neuropsychiatric sequelae

After resolution of PTA, overall IQ and posterior cognitive functions of language and visuospatial skills are often relatively intact and the residual neuropsychological deficits may not be easily detected by simple tests of cognitive function. A formal neuropsychological assessment of the patient’s memory, attention, and executive skills and their mental speed is thus mandatory, particularly late after severe injury when these problems play a major role in limiting independence.

Organic disorders of behaviour9 are often seen in tandem with cognitive dysfunction, and are usually described by a carer. Personality changes, of imprecise localising value, include egocentricity, childishness, irritability, aggressiveness, poor judgement, tactlessness, stubbornness, lethargy, disinterest, reduced drive and initiative, and often reduced rather than increased sexual interest. Occasionally more dramatic positive and impulsive, or negative and abulic, behaviours prevail.

Psychiatric sequelae including low mood, depression, and anxiety disorders are common after TBI, and often delayed in onset. Psychiatric illness, fewer years of formal education pre-injury, and a more dependent outcome predispose to the development of these problems.10 Depression may respond to a selective serotonin reuptake inhibitor or venlafaxine, and psychiatric referral may be necessary. Occasionally obsessive–compulsive disorders and psychoses occur in the absence of obvious premorbid psychiatric history, and the risk of suicide is increased.

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