A short thread on Cystocerebral Syndrome:

About a month ago I posted a crazy case w/ image on a gentleman with severe dementia who came in w/ worsening AMS. We found that he had Phlegmasia cerulea dolens (see below) from a severely distended bladder. Why the AMS though?

I thought it was likely due to the pain he was experiencing. He didn& #39;t have a UTI.

It wasn& #39;t until I listened to the @thecurbsiders recent episode with @aoglasser (who nailed the dx) on Post Op care, https://thecurbsiders.com/podcast/219 

What">https://thecurbsiders.com/podcast/2... is Cystocerebral Syndrome?

It is described as encephalopathy resulting from bladder distension and responding rapidly to bladder decompression

UTI is conventionally considered a sufficient cause of AMS, a recent review seriously questions the mechanistic role of UTI in AMS #jgs13851-bib-0006">https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851 #jgs13851-bib-0006">https://onlinelibrary.wiley.com/doi/full/...

A complementary brain–bladder interaction is though to occur throughhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="⏫" title="Nach oben zeigendes doppeltes Dreieck" aria-label="Emoji: Nach oben zeigendes doppeltes Dreieck">sympathetic tone 2/2 to bladder wall distention #jgs13851-bib-0007">https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851 #jgs13851-bib-0007

We">https://onlinelibrary.wiley.com/doi/full/... also know that bladder wall B-receptors are activated during bladder wall relaxation and filling #jgs13851-bib-0007">https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851 #jgs13851-bib-0007">https://onlinelibrary.wiley.com/doi/full/...

When some has a severe obstruction, central & peripheral adrenergic responses lead to https://abs.twimg.com/emoji/v2/... draggable="false" alt="⏫" title="Nach oben zeigendes doppeltes Dreieck" aria-label="Emoji: Nach oben zeigendes doppeltes Dreieck">catecholamine release

All of this will contribe to confusion & agitation, particularly in individuals w/ underlying cognitive deficits

A study in https://abs.twimg.com/emoji/v2/... draggable="false" alt="🐭" title="Mäusegesicht" aria-label="Emoji: Mäusegesicht">(yes they have to make an appearance when @aoglasser is mentioned) found an increase in locus coeruleus norepinephrine release & hyperarousal in those with bladder distention.

#jgs13851-bib-0008">https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851 #jgs13851-bib-0008">https://onlinelibrary.wiley.com/doi/full/... #jgs13851-bib-0009">https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851 #jgs13851-bib-0009">https://onlinelibrary.wiley.com/doi/full/...

Yes I am sure there is more than one mechanism at play.

But just knowing that the existence of bladder‐mediated sympathetic activation as the reason for his AMS is fascinating and raises the awareness of the dynamic interaction between bladder & brain.

Here is a great case report that I used to learn, https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13851

A">https://onlinelibrary.wiley.com/doi/full/... big thanks to @sargsyanz who helped lead a submission for this case to NEJM. Hopefully they agree.

This was his follow up image status post foley a few minutes later.