Objective:

Cerebellar, Hippocampal, and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) Syndrome is a rare toxidrome, presenting as severe encephalopathy. In the literature, this toxidrome is typically correlated with increased opioid receptor expression in the affected locations. This case report highlights the typical imaging findings in CHANTER syndrome in a patient with cocaine overdose and hypoxia.

Background:

We present a 30-year-old female, with a history of prior drug withdrawal related seizures with impaired consciousness compliant on Levetiracetam, polysubstance abuse, and schizophrenia, who was found unresponsive with unclear downtime, hypoxemic, with no clinical improvement after Naloxone administration. On presentation, she was noted to have abnormal right upper extremity twitching concerning for seizure in the setting of a severely depressed neurological exam. Treatment for myoclonic status epilepticus was initiated with continuous EEG monitoring. Significant laboratory findings included positive drug screen for cocaine, sodium: 128, severe rhabdomyolysis with acute renal failure requiring hemodialysis, acute leukocytosis, and multi-organ failure. The MRI brain demonstrated abnormal restricted diffusion involving the bilateral cerebellar cortex, bilateral hippocampi and mesial temporal lobes, with evidence of intracranial hypertension. Subsequent CT demonstrated cerebellar edema obliterating the fourth ventricle and bilateral supratentorial malignant cerebral edema. The differentials included status epilepticus, meningoencephalits, severe hypoxic ischemic injury. Empiric antibiotics and hypertonic saline were initiated for suspected meningitis and posterior fossa swelling respectively, a spinal tap was deferred given concerns for herniation. With aggressive ICU care, serial noncontract head CTs demonstrated radiographic improvement. She was successfully extubated five days after admission, and eventually discharged to LTAC with intact level of consciousness and moving all extremities.

Design/Methods:

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Results:

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Conclusions:

Although associated with opioids, CHANTER syndrome should be considered among young cocaine abusers with imaging findings of multifocal cerebral ischemia without vascular territory involvement. Aggressive ICU care and early incorporation of hyperosmolar agents can lead to better patient outcomes.