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Cerebral White Matter Lesions on Diffusion-Weighted Images

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Cerebral White Matter Lesions on Diffusion-Weighted Images diagnostics Article Cerebral White Matter Lesions on Diffusion-Weighted Images and Delayed Neurological Sequelae after Carbon Monoxide Poisoning: A Prospective Observational Study Sangun Nah 1 , Sungwoo Choi 1, Han Bit Kim 1, Jungbin Lee 2, Sun-Uk Lee 3 , Young Hwan Lee 1, Gi Woon Kim 1 and Sangsoo Han 1,* 1 Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea; [email protected] (S.N.); [email protected] (S.C.); [email protected] (H.B.K.); [email protected] (Y.H.L.); [email protected] (G.W.K.) 2 Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea; [email protected] 3 Department of Neurology, Korea University Medical Center, Seoul 02841, Korea; [email protected] * Correspondence: [email protected]; Tel.: +82-32-621-5116 Received: 29 August 2020; Accepted: 14 September 2020; Published: 16 September 2020 Abstract: Introduction: Carbon monoxide (CO) poisoning can result in delayed neurological sequelae (DNS). Factors predicting DNS are still controversial. This study aims to determine whether acute brain lesions observed using diffusion-weighted magnetic resonance imaging (MRI) following acute CO poisoning are related to the subsequent development of DNS. Methods: This prospective study was conducted on patients with CO poisoning treated at a university hospital in Bucheon, Korea. From August 2016 to July 2019, a total of 283 patients visited the hospital because of CO poisoning. Exclusion criteria included age under 18 years, refusing hyperbaric oxygen therapy, refusing MRI, being discharged against medical advice, being lost to follow-up, having persistent neurological symptoms at discharge, and being transferred from another hospital 24 h after exposure. Results: Of the 154 patients included in the final study, acute brain lesions on MRI (ABLM) were observed in 49 patients (31.8%) and DNS occurred in 30 patients (19.5%). In a logistic regression analysis, lower Glasgow coma scale score and higher exposure time were associated with DNS, and the presence of ABLM in white matter was significantly associated with DNS (OR 6.741; 95% CI, 1.843–24.660; p = 0.004). Conclusion: The presence of ABLM in white matter was significantly related to the occurrence of DNS. Early prediction of the risk of developing DNS through MRI may be helpful in treating patients with CO poisoning. Keywords: carbon monoxide poisoning; magnetic resonance imaging; neurotoxicity; white matter 1. Introduction Carbon monoxide (CO) is a colorless, tasteless, and odorless toxic gas produced by incomplete combustion of carbon-based fuel and material [1]. Because of these characteristics, patients often do not know they are affected and, in mild cases, diagnosis and treatment are often delayed because symptoms do not appear immediately. CO has 250 times greater affinity for hemoglobin (Hb) than oxygen, so it binds Hb and reduces oxygen transport. This is a major cause of mortality and morbidity associated with CO poisoning because this process can damage the brain and heart, which are vulnerable to ischemia [2]. Diagnostics 2020, 10, 698; doi:10.3390/diagnostics10090698 www.mdpi.com/journal/diagnostics Diagnostics 2020, 10, 698 2 of 11 DNS is one of the common sequelae of brain damage caused by CO poisoning, which can occur two days to six weeks after successful treatment for acute CO poisoning. DNS should be suspected if symptoms such as memory loss, movement disorder, and/or dementia appear [3]. Previous studies have suggested that old age, loss of consciousness at the time of exposure, and initial neurological abnormality are predictors of DNS following acute CO poisoning, but this remains controversial [4,5]. The predictive values of these factors appear inconsistent because of differences in types of patients, severity of CO poisoning, and diversity of measurement results [6]. Magnetic resonance imaging (MRI) is one of the most accurate tests for diagnosing ischemic brain lesions and brain diseases, such as demyelinating diseases, Alzheimer’s disease, and epilepsy [7,8]. In addition, one of the best ways to present acute ischemic brain lesions is MRI diffusion-weighted images (DWIs) [9,10]. The pathophysiology of CO poisoning results in apoptosis, abnormal inflammatory responses, and ischemia–reperfusion injury in the brain, which can cause ischemic brain tissue damage and demyelination of white matter [3]. Therefore, early ischemic lesions in CO poisoning can be found using MRI, especially DWIs. Previous studies reported that white matter hyperintensities and hippocampal atrophy were usually found on brain MRI in CO poisoning [11,12]. In other studies, the putamen, thalamus, and caudate nucleus were found to be affected, appearing as asymmetric focal hyperintense lesions in T2-weighted and FLAIR images [13,14]. Globus pallidus is also among the regions that are vulnerable to CO [12,15]. Like this, various brain lesions can be found in CO poisoning but there is no consensus on the MRI findings that are related with the development of DNS yet. This study investigated the association of acute brain lesion on MRI (ABLM), particularly on DWIs, with the occurrence of DNS. The relationship between patterns or locations of ABLMs and the occurrence of DNS was also investigated. 2. Methods 2.1. Study Design and Setting This prospective observational study was conducted using a CO registry and telephone interviews with all CO poisoning patients who visited the university hospital emergency department (ED) located in Bucheon, Korea. This study was approved by the hospital institutional trial review board (IRB file No. 2020-03-019). 2.2. Participant Selection Since August 2016, all patients visiting the ED of our institution with CO poisoning have been placed on the CO registry. All patients who had adequate history or physical examination after CO poisoning, and measured carboxyhemoglobin (COHb) values > 5% in non-smokers and >10% in smokers upon the first visit to the ED were considered to be suffering from CO poisoning. The present study was conducted on CO poisoning patients who visited from August 2016 to July 2019. We included patients who consented to hyperbaric oxygen (HBO) therapy. Patients were excluded if they were under 18 years of age, refused HBO therapy, refused MRI, were discharged against medical advice, were lost to follow-up, had neurological deficits persisting at discharge from the ED, and/or were transferred from another hospital 24 h after exposure (Figure1). According to our management protocol, patients were scheduled for MRI scans within 2 days of visiting the ED. However, MRI was not performed when patients or their proxy did not consent or when a medical condition contraindicated MRI scan. Diagnostics 2020, 10, 698 3 of 11 Diagnostics 2020, 10, x FOR PEER REVIEW 3 of 11 Figure 1. Flow chart of patient selection. Abbreviations: CO, carbon monoxide; HBO, hyperbaric Figure 1. Flow chart of patient selection. Abbreviations: CO, carbon monoxide; HBO, hyperbaric oxygen; MRI, magnetic resonance imaging. oxygen; MRI, magnetic resonance imaging. 2.3. HBO Therapy Indication and Protocol 2.3. HBO Therapy Indication and Protocol HBO therapy was delivered if the patient’s initial COHb was 25% (COHb 15% in pregnant ≥ ≥ women),HBO theretherapy was was a history delivered of lossif the of patient’s consciousness initial COHb or presence was ≥25% of neurological (COHb ≥ 15% abnormalities in pregnant regardlesswomen), there of COHb was a concentration, history of loss and of /orconsciousn there wasess apparentor presence cardiac of neur injury,ological such abnormalities as abnormal electrocardiogramregardless of COHb or elevationconcentration, of troponin and/or I. HBO there therapy was apparent cannot be cardiac applied injury, to endotracheal such as abnormal intubated patientselectrocardiogram in principle; or however, elevation when of troponin there were I. signsHBO oftherapy spontaneous cannot breathing be applied and to stabilization endotracheal of vitalintubated signs, patients HBO therapy in principle; was delivered. however, HBO when therapy there was were applied signs in of a monochamber,spontaneous breathing and treatment and wasstabilization conducted of invital three signs, sessions HBO at therapy intervals was of delivered. 6–12 h within HBO a day.therapy In the was first applied session, in thea monochamber, total duration ofand HBO treatment therapy was was conducted 150 min/session, in three andsessions the target at inte pressurervals of was6–12 3h atmospheres within a day. (absolute). In the first For session, later sessions,the total duration they were of aimed HBO fortherapy 120 min was/session 150 min/sess and 2 atmospheresion, and the target [16]. pressure was 3 atmospheres (absolute). For later sessions, they were aimed for 120 min/session and 2 atmospheres [16]. 2.4. Clinical and Laboratory Assessments 2.4. Clinical and Laboratory Assessments At the ED visit, we collected the following data for our registry: demographic data, medical comorbidities,At the ED vital visit, signs, we collected Glasgow the coma following scale (GCS), data CO for exposureour registry: time, demographic intentionality data, of poisoning, medical symptoms,comorbidities, and vital laboratory signs, Glasgow results. We coma also scale prospectively (GCS), CO collected exposure neurological time, intentionality symptoms of and poisoning, signs at discharge.symptoms, DNS and werelaboratory defined results. as neurological We also prospe abnormalitiesctively collected that occurred
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