Clinical and Imaging Features of Osmotic Demyelination Syndrome due to Glucose Disturbances: A Systematic Review of Case Reports and Case Series
Deya'a Alasmar1, Ahmad Alzoubi1, Ma’moun Othman1, Dema Alzu’bi1, Ahda Jbarah2, Firas Kaddouh, MD, MHS3
1Hashemite University, Jordan, 2Emory University, GA, 3Department of Neurology, University of Arizona College of Medicine – Tucson
Objective:
To systematically characterize the clinical and radiological features of osmotic demyelination syndrome (ODS) associated with glucose disturbances.
Background:
ODS, which includes central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM), results from demyelination following rapid alterations in serum osmolality. Although classically linked to rapid correction of hyponatremia, an increasing number of reports describe ODS secondary to glucose abnormalities or their correction, as glucose is also an osmotically active molecule. However, the clinical presentation, imaging patterns, and outcomes of glucose-related ODS have not been comprehensively summarized.
Design/Methods:
A systematic search of PubMed, Web of Science, Scopus, and Embase was conducted through August 1, 2025. Statistical analyses were performed using SPSS. Comparative analyses between CPM, EPM, and combined lesion groups were conducted using Chi-square testing with Monte Carlo simulation (10,000 samples). Quality assessment was assessed using the JBI checklist. The protocol was registered in PROSPERO (CRD420251146640).
Results:
Ninety-seven patients with 100 ODS episodes were identified from 93 publications. The mean age was 44.6 ± 20.2 years; 57 (58.8%) were male. Hyperglycemia was present in 91% of cases and hypoglycemia in 9%. CPM occurred in 64 cases, EPM in 11, and combined lesions in 25. The most common clinical manifestations were confusion or altered mental status (59%), dysarthria (50%), ataxia (38%), and paresis (31%). EPM and combined lesions were associated with higher rates of confusion (p = 0.004) and coma (p = 0.001), whereas dysphagia was more frequent in CPM (p = 0.010). Facial symptoms were predominantly observed in EPM (p = 0.014). Imaging findings most frequently involved the pons (88%), followed by cerebellum (14%), basal ganglia (13%), thalamus (6%), midbrain (5%), and internal capsule (4%).
Conclusions:
ODS related to glucose disturbances, though uncommon, should be considered in patients experiencing rapid glucose shifts who develop acute neurological symptoms. Early recognition is essential to optimize diagnosis and management.
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