 Hello, everyone. Myself, Dr. Mohammad Ashraf, junior resident third year in the department of radio diagnosis, JNMCH, AME Oligo. Presenting a case report of the central pontine myelinalysis with extra-pontine myelinalysis. Here, the clinical history, a 46-year male non-diabetic, non-hypertensive, non-alcoholic presented to emergency department with a chief complaint of vomiting for 20 days and khabrahat for seven days. And episodes of abnormal movements for five days. He came from a private hospital where he was managed initially for the same. An NCCT head was done that turned out normally study. At the time of presentation, serum electrolyte was done. There was severe hyponatremia. Serum sodium was 108 milligram per deciliter. CBC, RFP, LFT were within normal limit. There is a history of correction of sodium turned by 3% NSEL. And repeat, serum electrolyte was done after 24 hours. Serum sodium was turned out 128 milligram per deciliter. And after a few days, patient again developed episodes of abnormal moments, difficulty in breathing, khabrahat. On neurological examination, spasticity and disintegrated posture by little hypotonia in the upper limbs. Babich's reflex on the right side and normal plant reflex on the left side. Tracheostomy was done for the airway maintenance. And MRI brain was advised. Here are the images of MRIs. This is the T1 axial image at the level of pons and T2 axial image at the level of basal anglia. The T1 image, there is a few hyper-intensities seen in the pons region, few hyper-intensities in pons. And in T2 image, at the level of basal anglia, showing symmetrical areas of hyper-intensities in bilateral potted globus pallidus and putamen. Again, this is T2 axial image at the level of pons and diffusion weighted image. T2 axial showing three linear hyper-intensities forming omega sign or trident sign, giving restriction on diffusion weighted imaging. So this is the characteristic omega sign or trident sign. And again, this is the T2 flare image at the level of basal anglia region and showing multiple hyper-intensities seen in bilateral basal anglia region and showing diffusion restriction and diffusion weighted imaging in the corresponding areas. This is the axial image of diffusion weighted imaging at the level of pons showing characteristic trident sign. The trident sign is due to the involvement of transverse pontine fiber and relative sparing of descending corticospinal tract. That is responsible for this characteristic omega-shaped appearance. So these all are MRI brain finding. The symmetrical areas of altered signal intensity involving bilateral potted globus pallidus, putamen, pons, which are appearing hyper-intense and T1 weighted imaging and hyper-intense T2 flare with restriction on diffusion weighted imaging with no evidence of blooming on SWI. So the diagnosis was central pontine myelinalysis with extrapontine myelinalysis. Coming to the discussion, central pontine myelinalysis, which is a component of osmotic demyelination syndrome, is a frequent neurological complication that follows rapid correction of hyponatremia. Electrolyte abnormalities are frequently encountered during hospitalization, which are usually followed by aggressive normalization of the involved electrolyte. The osmotic demyelination syndrome comprising central pontine myelinalysis and extrapontine myelinalysis are common neurological complication associated with abrupt osmotic fluctuation. Alcoholics and malaria patients generally are deficient in organic osmolites. And these conditions may put at greater risk for developing osmotic demyelination syndrome. Some other additional comorbidities that predispose osmotic demyelination syndrome like prolonged use of diuretics, transplantations, extensive burns. The sites of extrapontine myelinalysis includes mesylvanglia and cerebral white matter, and less commonly the peripheral cortex, hippocampus, and lateral geniculate bodies. Extrapontine myelinalysis commonly occur in conjunction with central pontine myelinalysis. However, it may also occur in isolation. These are the differential diagnosis for central pontine myelinalysis or extrapontine myelinalysis. Multiple sclerosis, brain system, in fact, pontine new plans such as astrocytoma, CNS lymphomas, brain system metastasis. A treatment in the treatment prevention, in the treatment of central pontine myelinalysis is primarily aimed at prevention. Then reintroduction of hyponatremia. The current recommendations are to correct the sodium not more than 8 to 12 milliequivalent per liter for 24 hours. Supportive care measures include ventilator support, intense physiotherapy, and rehabilitation, and anti-partisanism drugs. Promenosis some patients may recover completely however, six months survival rate is only 5%. Thank you.