Journal Article

CHANTER syndrome in the context of pain medication: a case report

Klingebiel, Randolf, Wulff, Leonard, Jansen, Nils, Schäbitz, Wolf-Rüdiger, Conty, Moritz

2024

Overview

Background CHANTER (Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion) is a recently described syndrome occurring in the context of drug abuse. While clinical findings are rather unspecific (disorientation, unresponsiveness), MR imaging (MRI) discloses a characteristic pattern (restricted diffusion in the basal ganglia and hippocampi, cerebellar oedema and haemorrhage), allowing for timely diagnosis before complications such as cerebellar swelling and herniation do occur. Here we report a case of CHANTER primarily based on imaging findings, as there was no evidence of drug abuse on admission. Case presentation A 62-year-old Patient was admitted to our hospital after being unresponsive at home. Prehospital intubation was performed, which limited neurological assessment. Under these circumstances no obvious symptoms could be determined, i.e. pupils were isocoric and responsive, and there were no signs of seizures. While the initial CT scan was unremarkable, the subsequent MRI scan showed a distinct imaging pattern: moderately enhancing areas in the basal ganglia and hippocampi with diffusion restriction, accompanied by cerebellar haemorrhage and oedema (Figs. 1 and 2). A comprehensive clinical and laboratory work-up was performed, including drug screening, spinal tap, Holter ECG, echocardiography and EEG. The only conspicuous anamnestic finding was a chronic pain syndrome whose medication had been supplemented with opioids two months previously. The opioid medication was discontinued, which led to a rapid improvement in the patient’s clinical condition without any further measures. The patient was able to leave the intensive care unit and was discharged 10 days after admission without persistent neurological deficits. Conclusion Familiarity with typical MRI patterns of toxic encephalopathy in patients from high-risk groups, such as drug abusers, is crucial in emergency neuroradiology. In the presence of typical MRI findings, CHANTER syndrome should be included in the differential diagnosis, even if there is no history of drug abuse, to avoid delay in diagnosis and treatment.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Basal ganglia / Basal Ganglia - diagnostic imaging / Basal Ganglia - pathology / Brain Edema - chemically induced / Brain Edema - diagnostic imaging / Carbon monoxide poisoning / Case Report / Case reports / Causes of / Cerebellum / CHANTER syndrome / Chronic pain / Cocaine / Comparative analysis / Complications and side effects / Computed tomography / Diagnosis / Differential diagnosis / Dosage and administration / Drug abuse / Drug overdose / Drug screening / Drug therapy / Echocardiography / Edema / EKG / Encephalopathy / Familiarity / Hemorrhage / Hippocampus / Hippocampus - diagnostic imaging / Hippocampus - pathology / Humans / Hypoxia / Ischemia / Magnetic resonance imaging / Magnetic Resonance Imaging - methods / Medical imaging / Medicine / Medicine & Public Health / Metabolism / Middle Aged / MRI / Narcotics / Nervous system diseases / Neurochemistry / Neuroimaging / Neurological diseases / Neurology / Neurosurgery / Opioids / Pain / Patients / POUNCE syndrome / Risk groups / Seizures / Stroke / Syndrome / Toxicity