Opioid overdose in a child: case report and discussion with emphasis on neurosurgical implications

Reisner, Andrew; Hayes, Laura L.; Holland, Christopher M.; Wrubel, David; Kebriaei, Meysam; Geller, Robert J.; Baum, Griffin R.; Chern, Joshua J.

doi:10.3171/2015.4.peds14667

Cited by 20 publications

(33 citation statements)

References 34 publications

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“…In both instances, patients had good clinical outcomes though with some deficits considering the life-threatening nature of their presentations. To our knowledge, there are only two other reported cases of children requiring surgical posterior fossa decompression for malignant cerebellar edema after accidental prescription opioid ingestion (9, 10). Both cases had nearly identical clinical courses and radiographic findings when compared to our patients.…”

Section: Discussionmentioning

confidence: 99%

“…Our comprehensive review of the literature revealed 8 additional cases of acute pediatric opioid-induced leukoencephalopathy with cerebellar edema (Table 1) (9, 10, 25–30). Patients were toddlers, who accidentally consumed their caregiver’s prescription opiates orally with the exception of one case in which administration occurred through a transdermal fentanyl patch (27).…”

Section: Discussionmentioning

confidence: 99%

“…Often, the first study obtained in the emergency department was a non-contrast head CT, which revealed bilateral and symmetric cerebellar hypoattenuation, with a variable element of cisternal effacement and hydrocephalus, dependent on the magnitude of mass effect exerted by parenchymal edema. On MRI, cerebellar diffusion restriction on DWI, and hyperintensity on T2-weighted and fluid attenuation inversion recovery sequences were frequently described (9, 10, 25, 28). Restricted diffusion, albeit most marked in the cerebellum, was also present in watershed areas of the deep white matter, where circulatory redundancy between the anterior and posterior circulation is minimal.…”

Section: Discussionmentioning

confidence: 99%

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Malignant Cerebellar Edema Subsequent to Accidental Prescription Opioid Intoxication in Children

et al. 2017

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We present two recent cases of toddlers who developed malignant cerebellar edema subsequent to accidental ingestion of prescription opioids. Both children presented acute neurological decline, hydrocephalus, and tonsillar herniation requiring emergent ventricular drain placement, suboccipital craniectomy, and partial cerebellectomy. Together with several other reports, these cases suggest the existence of an uncommon yet severe syndrome of acute opioid-induced malignant cerebellar edema. We hypothesize that the condition results from a combination of primary opioid receptor-mediated changes in neuronal metabolism that are exacerbated by secondary hypoxic insult. If recognized promptly, this syndrome can be treated with emergent neurosurgical intervention with good clinical outcomes. These cases also illustrate the unintended consequences and innocent victims of the spiraling prescription opioid epidemic, which will likely increase in prevalence. Recognition of this syndrome by clinicians is thus critical.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Malignant Cerebellar Edema Subsequent to Accidental Prescription Opioid Intoxication in Children

et al. 2017

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“…Neurobehavioral presentations typically include altered mental status, psychomotor changes, depression, anxiety, visuospatial deficit, coma, or death, while language capabilities are characteristically spared [1, 2, 3]. It is important to note that cases of acute TLE may present with sudden increased intracranial pressure, acute hydrocephalus, and herniation due to predominant cerebellar involvement.…”

Section: Clinical Presentationmentioning

confidence: 99%

“…Although the exact mechanism of toxicity remains speculative, patterns of injury have been described. Histopathology demonstrates white matter vacuolization and spongiform defects as hallmarks of TLE [1, 2, 3].…”

Section: Introductionmentioning

confidence: 99%

Opioid-induced toxic leukoencephalopathy: A case report and review of the literature

Wheaton

Breznak

DaSilva

et al. 2019

Heliyon

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ImportanceReports of toxic leukoencephalopathy (TLE) due to opioids have been extensively documented within the adult literature. There is a paucity of literature with respect to the incidence, complications, and outcomes of TLE in the pediatric population.ObjectiveTo describe a rare complication of opioid ingestion in the pediatric population and serve as the first large review of published cases of opioid-induced leukoencephalopathy. Thirteen case reports with varying treatments are herein reviewed in addition to our own case. The range of treatment modalities, morbidity and mortality are broad and outcomes secondary to supportive care versus neurosurgical intervention is explored.Evidence reviewAll cases of pediatric opioid-induced toxic leukoencephalopathy published on pubmed and google scholar were included in this review.FindingsWe report the case of a 4-year old male surgically treated for acute oxycodone-induced TLE who initially presented with Glascow Coma Scale of 4 and a comatose state for weeks. Over the next several months he recovered with spasticity of all extremities, oral aversion, substantial vision loss, and the ability to speak in short sentences. In addition, we found thirteen other reported cases of opioid-induced leukoencephalopathy reported in the literature. The treatment approaches described range from supportive care alone, to invasive neurosurgical interventions including placement of extraventricular drains, removal of hemorrhagic tissue, and craniectomy. The outcomes of patients with opioid-induced leukoencephalopathy is also variable. Reports demonstrate a range of outcomes that include patients who died to those with no residual neurologic deficits.ConclusionsThis review of reported pediatric cases of opioid-induced leukoencephalopathy highlights the importance of early neurosurgical intervention for prevention of devastating outcomes.

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Opioid neurotoxicity: A case series and review from members of the Child Neurology Society Neurocritical Care Special Interest Group

Boerwinkle,

Sweatt,

Grzezulkowska

et al. 2024

Annals of the Child Neurology Society

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ObjectiveThe Child Neurology Society 2023 Annual Meeting Neurocritical Care Special Interest Group discussed pediatric opioid use–associated neurotoxicity with cerebellar edema (POUNCE). Inspired by the discussion and the suspicion of an underrecognized severe form of the disorder, we provide a case series and literature review on this important and emerging topic.MethodsThe meeting was moderated by coauthor DSM, with formal presentation by coauthor AG, and supplemented with a supporting case by coauthor VLB. The attendees, by show of hand, were queried for experience with direct care of children in the critical care unit with neurotoxicity from opioid exposure. These meeting elements informed our literature review and case series.ResultsA key focus of the meeting was the importance of interdisciplinary communication regarding POUNCE, emphasizing the necessity for neurosurgical assessment due to mass effect. Approximately 10 of 40 attendees, representing different US hospitals, reported caring for children with opioid neurotoxicity and concern for increased intracranial pressure. Described during the meeting was a 2‐year‐old girl with opioid exposure, rapidly worsening neurological exam, and transforaminal herniation concerning for severe POUNCE syndrome and impact on brain networks by resting‐state functional magnetic resonanance imaging (rs‐MRI). After surgical decompression did not improve her neurological function, she underwent rs‐MRI, electroencephalogram, and MRI. The networks indicated better neurological function than the exam, consistent with outcome. In contrast, the second patient, was an 11‐month‐old boy with fentanyl exposure who was treated for opioid overdose and closely monitored clinically. He did not require surgical intervention and has recovered well.InterpretationThese patients add to the few publications documenting the management of POUNCE, which may require urgent posterior cranial fossa decompression, and highlight the potential for good outcomes. Additionally, this is the first report documenting rs‐fMRI for this condition, which was consistent with the patient's outcome.

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Opioid overdose in a child: case report and discussion with emphasis on neurosurgical implications

Cited by 20 publications

References 34 publications

Malignant Cerebellar Edema Subsequent to Accidental Prescription Opioid Intoxication in Children

Malignant Cerebellar Edema Subsequent to Accidental Prescription Opioid Intoxication in Children

Opioid-induced toxic leukoencephalopathy: A case report and review of the literature

Opioid neurotoxicity: A case series and review from members of the Child Neurology Society Neurocritical Care Special Interest Group

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