Imaging in a confused patient: Infections and Inflammation

Transcription

1 American Society of Neuroimaging Imaging in a confused patient: Infections and Inflammation January 21, 2017 Los Angeles, California Joshua P. Klein, MD, PhD, FANA, FAAN, FASN Chief, Division of Hospital Neurology Associate Professor of Neurology and Radiology Brigham and Women s Hospital & Harvard Medical School

2 Disclosure I have no financial interests or disclosures to report that are relevant to the content of this presentation.

3 Inflammation as a cause of confusion Infectious meningitis, encephalitis, vasculitis, abscess Non-infectious meningitis, encephalitis, vasculitis, tumor, demyelination, trauma, toxic, metabolic

4 Confusion History: Symptoms, pace, review of systems, coincident non-neurologic disease, medication changes, drug exposures Physical exam: Level of consciousness, localizing signs Secondary phenomena: hydrocephalus, mass effect, herniation

5 Confusion plus syndromes 1. Viral encephalitis: + fever, seizures 2. Limbic encephalitis: + seizures, behavior change 3. Wernicke: + ataxia, oculomotor paresis 4. ADEM: + fever, preceding illness 5. CJD: + progressive, seizures, myoclonus 6. NPH: + ataxia, incontinence 7. PML: + immunosuppression 8. PRES: + hypertension, exposure to chemo 9. Non-convulsive status epilepticus: + seizures 10. Serotonin syndrome, NMS: + med exposures 11. Acute hepatic encephalopathy: + elevated ammonia 12. Pontine (and extrapontine) myelinolysis: + hypo-na

6 Confusion What is the relationship of confusion to consciousness and arousal? Reticular Activating System Danaila L and Pascu ML, 2013

7 Confusion Conscious: state of awareness of self and environment, and responsiveness to external stimulation and inner need. Levels of consciousness or arousal: awake, drowsy, stuporous, obtunded, comatose Unconscious: state of unawareness of self and environment, coupled with diminished responsiveness to environmental stimuli.

8 Neuroanatomy, alteration of arousal JNEN 2013;72:505

9 NEJM 2007;356:166

10 A 53 year-old woman who fell down stairs

11 A 53 year-old woman who fell down stairs JNEN 2013;72:505 JNEN 2013;72(6):505

12 Coma, trauma to ARAS

13 Coma, injury to ARAS thalamic projections Basilar thrombosis CNS lymphoma

14 Coma, ischemia to ARAS cortical projections

15 Meningeal inflammation

16 Meningitis, compartments (pachymeninges) (leptomeninges) Skull Dura Outer arachnoid ~ CSF ~ inner arachnoid Pia Brain epidural subdural subarachnoid intraparenchymal intraventricular

17 Pachymeningitis (dura)

18 Pachymeningitis (dural myeloid sarcoma) T1-post DWI ADC

19 Leptomeningitis (pia, carcinomatous)

20 Meningitis (carcinomatous) Klein JP, Handb Clin Neurol 2016;136:923

21 Leptomeningitis in sarcoidosis Klein JP, in Youmans and Winn Neurological Surgery, 7 th Ed, 2016

22 Leptomeningitis in tuberculosis Axial graphic shows the early capsule Klein formation of JP, an abscess in Youmans with central liquified and necrosis Winn and inflammatory Neurological debris. Collagen and Surgery, reticulin form the 2016 well-defined abscess wall. Note the surrounding edema.

23 Leptomeningitis and vasculitis Lymphocytic meningitis due to HSV-2 Ischemic infarctions and hemorrhages Leptomeningeal enhancement J Neurovirology 2014;20:419

24 Meningitis (dura & pia) in infection

25 Cerebral inflammation

26 Encephalitis, limbic (VGKC with thymoma)

27 Encephalitis, EEE virus

28 HIV encephalitis AIDS Pt Care STDS 2012;26:383

29 HSV-1 encephalitis Adams and Victor s Principles of Neurology, 10 th Ed, 2014

30 HSV-3 (VZV) encephalitis, vasculitis NEJM 2000;342:635

31 HHV-5 (CMV) ventriculo-encephalitis opportunistic, associated with ventriculo-encephalitis, also, meningitis, transverse myelitis, and radiculomyelitis STATdx

32 HHV-6 encephalitis opportunistic, medial temporal lobe tropism STATdx

33 JC virus encephalitis Am J Hematol 2016;91:1057

34 Creutzfeldt-Jakob disease, sporadic JNNP 2007;78:664

35 Creutzfeldt-Jakob disease, sporadic

36 Hypoxemic encephalopathy

37 Hypoxemic-ischemic encephalopathy

38 Delayed post-hypoxic leukoencephalopathy 4 weeks post-inhalation 3 weeks later 10 months later

39 Heroin inhalation toxicity AJR 2003;180:847

40 Cerebritis Abscess Axial graphic shows early cerebritis, the initial phase of abscess formation, in the frontal lobe. There is a focal unencapsulated mass of petechial hemorrhage, inflammatory cells, and edema. STATdx

41 Cerebritis Abscess Early cerebritis: Patchy enhancement masses of PMNs, hyperemia Late cerebritis: Intense, irregular rim enhancement coalescence of masses, necrosis Early capsule: Well-defined, thin-wall, enhancing rim collagenous capsule, liquefied core Late capsule: Cavity collapses, capsule thickens thick wall of collagen and fibroblasts Ddx: glioblastoma, metastases, demyelination, hematoma, subacute infarction.

42 Cerebral abscess T1-post DWI ADC

43 Tuberculoma Axial graphic shows the early capsule formation of an abscess with central liquified necrosis and J inflammatory Clin Neurosci debris. Collagen and 2013;20:1599 reticulin form the well-defined abscess wall. Note the surrounding edema.

44 Neurocysticercosis

45 Tumefactive demyelination Klein JP, in Youmans and Winn Neurological Surgery, 2016

46 ADEM

47 PRES J Clin Oncology 2016;34(2):1

48 Summary Confusion may result from inflammation of the brain and meninges. Infectious and non-infectious inflammation can cause meningitis, encephalitis, vasculitis.

49 Summary The history and physical exam are key. Identify the clinical syndrome, then correlate to imaging. Assess all compartments. Anticipate secondary effects of primary disease process.