A Case of Cerebellar Hippocampal and Basal Nuclei Transient Edema With Restricted Diffusion Syndrome With Poor Clinical Outcome

Abstract

Cerebellar hippocampal and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome is a specific pattern of restricted diffusion in the hippocampi and cerebellum identified on brain imaging by clinicians in patients who present with altered mental status in the context of substance intoxication. These patients developed obstructive hydrocephalus a couple of days into their hospitalization that required therapy with osmotic agents and/or surgical interventions (i.e., drains and decompressive craniectomy). In prior cases published, many of the patients had good recovery. The case we present is of a woman who presented after polysubstance use and was found to have brain imaging findings supportive of CHANTER syndrome. Although she was treated with aggressive osmotic therapy and surgical interventions, she ultimately developed irreversible brain damage leading to an overall poor prognosis for recovery. Our case suggests variability in the progression of the syndrome and demonstrates the need for further studies to examine whether the substance of use and the patient's chronic medical conditions may contribute to the degree of recovery.

Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome in the setting of opioid and phencyclidine use

“…While some patients in the prior case series had poor prognoses or died, most had favorable outcomes with near-complete recovery or mild-to-moderate residual impairment. Like many diagnosed with CHANTER syndrome, our patient demonstrated a swift and complete recovery after presenting with severely declined cognitive function and requiring intubation [ 1 , 4 , 5 , 18 ]. However, our patient differed from most prior cases in that they had cerebellar edema and some degree of mass effect on the 4th ventricle, without resulting in obstructive hydrocephalus [ 1 , 4 , 5 , 18 ].…”

“…Like many diagnosed with CHANTER syndrome, our patient demonstrated a swift and complete recovery after presenting with severely declined cognitive function and requiring intubation [ 1 , 4 , 5 , 18 ]. However, our patient differed from most prior cases in that they had cerebellar edema and some degree of mass effect on the 4th ventricle, without resulting in obstructive hydrocephalus [ 1 , 4 , 5 , 18 ]. In our case, the patient also had cerebellar edema and some degree of mass effect on the fourth ventricle, which was not to the extent to cause obstructive hydrocephalus.…”

Cerebellar, Hippocampal, and Basal Nuclei Transient Edema With Restricted Diffusion (CHANTER) Syndrome: Radiologic Features and Findings

“…Acute management typically involves opioid reversal with naloxone, an opioid antagonist. Initial CT findings revealing acute cerebellar edema with secondary obstructive hydrocephalus are managed either medically with mannitol and hypertonic saline or surgically with temporary ventricular shunting and decompressive craniectomy [ 4 5 ]. MRI commonly demonstrates diffusion restriction in the cerebellar cortices and hippocampi symmetrically and in the bilateral basal ganglia asymmetrically, with variable cerebral cortical and white matter involvement.…”

CHANTER Syndrome and mesenteric ischemia presenting concurrently, a case report and literature review

“…Although there have been known acute neurologic injuries associated with cocaine and/or other substance abuse, such as acute ischemic stroke, Hypoxic-Ischemic Encephalopathy (HIE), Heroin-associated spongiform leukoencephalopathy (HASL), CHANTER was described recently as a radiologic and clinical syndrome with typical imaging findings [8] . As clinical presentations can overlap, it is crucial to differentiate CHANTER from other substance-use-related acute neurologic injuries, given its distinct clinical course, potential complications, and management, while also acknowledging the heightened risk of obstructive hydrocephalus because of cerebellar edema [8] , [9] , [10] . CHANTER is characterized by bilateral symmetric abnormal restricted diffusion areas involving basal ganglia, hippocampus, and cerebellar hemispheres.…”