Ischemic and hemorrhagic necrosis of the pons with anatomical location similar to that of central pontine myelinolysis in a chronic alcoholic patient.

An autopsied case of recent ischemic and hemorrhagic necrosis of the pons is reported, in which the anatomical site of the lesion is similar to that observed in central pontine myelinolysis. The patient, a 46-year-old woman, was a chronic alcoholic who had been treated with large quantities of physiological saline and glucose solution at 5% during a period of nine days before death. On the fifth day of treatment she developed hypernatremia, which persisted for three days. From hyperglycemia on the day of admission, her serum glucose levels subsequently dropped to normal values and then rose again on the day of death. Examination of the brain revealed recent ischemic and hemorrhagic necrosis affecting the central portion of the upper two thirds of the pontine basis, in triangular, bilaterally symmetrical pattern, and extending into the tegmentum. There was no evidence of demyelination or degradation products of the myelin. No vascular alterations or thrombi were identified in the pontine vessels surrounding the lesion. The differential diagnosis of pontine infarct, central pontine myelinolysis, and Duret's hemorrhage is discussed. In analysing the possible etiology and pathogenesis of the lesion, it is suggested that osmotic vascular injuries induced by fluctuating levels of serum sodium and glucose may lead to edema and demyelination similar to that observed in central pontine myelinolysis and, rarely, to necrosis and hemorrhage, as in the present case.