Themes Non-Traumatic Intracranial Emergencies

Transcription

1 Themes Non-Traumatic Intracranial Emergencies Diffuse Lesion: Infection vs Infarction Focal Lesion: Infection vs Tumor Kevin Abrams, M.D. Chief of Radiology Medical Director of Neuroradiology & MRI Baptist Hospital, Miami, FL Disclosures Diffuse: Infection vs Infarction I disclose that I serve as a consultant to Keystone Heart. My presentation will not include discussion of off-label or unapproved usage. 1

2 Basic Vascular Distributions NCCT 2

3 PCA Infarct Basic Vascular Distributions PCA 3

4 Ant Ch Art or MCA P C A M C A 4

5 MCA Infarct Basic Vascular Distributions Anterior Choroidal Art. Infarct Next branch above pcom Besides choroid plexus supply, important supply to uncus and post limb int. capsule 5

6 Case 3 PCA Ant Ch Art 6

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8 64 yo male with crohns and dipolpia 4/19 8

9 Several days before Case 4 Invasive Fungal sinusitis aspergillosis 9

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11 Herpes Encephalitis (Type I) A necrotizing encephalitis which is both viral and indirect immune mediated that has a predilection for the medial temporal lobes, inferior frontal lobes, limbic system Bimodal age dist. <20 (usu. primary 1/3) and >50(usu. latent reactivation 2/3) thru olfactory bulbs or trigeminal ganglia Mortality: 70% if untreated; 19% if treated Morbidity: 50% survivors have moderate to severe deficits Early initiation of Rx (Acyclovir) is key for Px Herpes Encephalitis (Type I) Symptoms: fever 90%, ha 80%, psy 70%, sz 67%, focal weakness 33%, memory 24% Imaging: swelling med. temp lobes, frontal bases, limbic system, insula. Cingulate gyrus; freq bilat, inc FLAIR, inc T2 DWI restricted, may be hemorrhagic, +/- enhancement CSF: mono pleo, rbc s, inc pro., PCR 96% sens., 98 % spec. EEG: focal spike &slow or periodic sharp waves over temporal lobes. 11

12 Herpes 2 nd Case Insula + Medial Temporal Lobe= Herpes Encephalitis tpo 12

13 Herpes 3 rd Case 13

14 NCCT CECT Case 5 14

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16 Limbic Encephalitis First described in the 1960 s Autoimmune: Ab s against 1. intracellular antigens:hu (SLSC), Ma2(testis nsclc), CV2/CRMP5(sclc, thymoma), amphiphysin, (breast, sclc) 2. cell mb anitgens: VGKC and NMDAR (thymoma, ov dermoid) Limbic encephalitis and variants, Tuzun etal, The Neurologist, vol 13 no.5, Sept 2007 Limbic Encephalitis Diag Crit. Paraneoplastic limbic encephalitis: Path demonstration, OR All 4 of the following: 1.Short trm mem loss, sz, psy sx s sugg limbic sys 2.<4 yr from onset of neuro sx s and cancer dx 3.exclusion mets, infn, metabolic, stroke, side effects of therapy 4. at least one of the following: CSF with inflamm findings MRI flair or T2 uni or bilat temp lobe hyper EEG with epileptic or slow activity focally involving temp lobes 16

17 Case 6 17

18 MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Initially described in 1984 Most commonly caused be A to G transition mutation at position 3243 of the mitochondrial genome (inherited matrinlieally- mom only!) Impairment of OXPHOS (multi-step process to generate ATP); shunt from pyruvate to lactate -> lactic acidosis Clinical Syndrome: 1. stroke like syndrome before age 40; 2. encephalopathy sz s &/or dementia; 3. lactic acidosis (serum or csf) &/or ragged red fibers Stroke-like sx s: episodes of partially reversible aphasia, hemianopsia, cortical blindness and eventual dementia MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Imaging: temporal, parietal and occipital lobes not respecting vasc territories. Mostly cortical but may involve adj. wm.; DWI bright but usu not restricted but can be. Lesions may fluctuate and go from side to side with eventual cortical atrophy. MRS: markedly elevated lactate. CT: B.G. Ca++ Other organ systems: muscles-exercise intolerance, cardiac- conduction (WPW) cardiomyopathy (concentric hypertrophy), endocrine- DM II, short stature, GI Tx: no effective rx,?coq10 other cocktails MELAS, Sproule & Kaufmann, Ann NY Acad Sci 1142,

19 Case 7 Dka seizure disorder Csf clean but strep in blood 19