Non-Traumatic Neuro Emergencies
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1 Department of Radiology University of California San Diego Non-Traumatic Neuro Emergencies John R. Hesselink, M.D.
2 Nontraumatic Neuroemergencies 1. Acute focal neurological deficit 2. Worst headache of life 3. Acute / Increasing confusion & obtundation 4. Acute / Progressive visual deficit 5. Acute / Progressive myelopathy
3 Acute Focal Neurological Deficit
4 Acute Focal Neurological Deficit Arterial thrombosis, occlusion, dissection or embolus Brain hemorrhage Hypotension / Hypoxia Venous / sinus occlusion Cortical mass lesion
5 Neuroradiological Workup MR imaging T2WI & FLAIR GRE Diffusion T1WI with gadolinium MRA /MRV Angiography Diagnosis Thrombolysis Angioplasty
6 History: 47 y/o man with von-hippel-lindau disease & new left arm weakness
7 {Page 2} DWI ADC Dx: Infarct & MCA stenosis
8 Case 1 History: 32 y/o woman with headache, confusion & right sided weakness
9 {Page 2} Question?
10 What can be hyperintense on T1-weighted images? 1. Fat 2. Subacute blood 3. Proteinaceous fluid 4. In-flow enhancement 5. Gadolinium enhancement 6. All of the above
11 Confusion & weakness {Page 3} Dx: Thrombosis of superior sagittal sinus, left transverse sinus & deep venous system
12 Venous / Sinus Occlusion Causes Hypercoagulable state Pregnancy Sepsis Dehydration Paranasal sinus or mastoid infection Neoplastic invasion
13 Case 2 History: 59 y/o woman with headache and left-sided weakness
14 1 Weakness {Page 2} 2 T1 - FATSAT T2W 3
15 Dx: Right ICA dissection {Page 3}
16 History: 43 y/o man with sudden onset of right face & arm weakness Case
17 {Page 2}
18 {Page 3} Question? Dx: Hyperacute hemorrhage & AVM
19 What is the cause of the hyperintensity on the DWI image? 1. Restricted diffusion 2. Subacute blood 3. T2 shine through 4. Gadolinium enhancement 5. Turbulence
20 Intracranial Hemorrhage Non-traumatic Hypertension 36% Aneurysm 36% 11% 17% Other AV Malformation Other causes: bleeding into tumor, hypocoagulable state, hemorrhagic infarction and iatrogenic
21 Case 10 History: 5 y/o girl with seizures
22 {Page 2} Question? Diffusion image
23 How does the DWI image help in differential diagnosis? 1. Indicates hemorrhage 2. Excludes a bacterial abscess 3. Excludes toxoplasmosis 4. Favors a tumor
24 {Page 3} Dx: Amoebic abscesses
25 Pyogenic Brain Abscess Lactate Alanine Cytosolic Acid Acetate Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece
26 Worst Headache of Life!!
27 Worst Headache of Life Subarachnoid hemorrhage Acute meningitis Migraine Imaging CT for SAH Lumbar puncture If no SAH, then MRI Intervention Ablation of the aneurysm Angioplasty for vasospasm
28 History: 63 y/o man collapsed while preaching on Sunday 369
29 {Page 2} Dx: p-comm aneurysm
30 Case 9 History: 45 y/o female with severe headache
31 {Page 2}
32 Headache {Page 3} Dx: SAH due to bilobed basilar tip aneurysm
33 History: 54 y.o. man with severe headache
34 {Page 2} Dx: Cocci meningitis
35 Acute / Increasing Confusion and Obtundation
36 Acute / Increasing Confusion & Obtundation Obstructive hydrocephalus Brain stem or basal ganglia hemorrhage Brain herniation Encephalitis Meningitis Metabolic & toxic disorders Imaging: CT and MRI
37 Case 7 History: 34 y/o man with intermittent chronic headaches & acute decreased mental status
38 Headaches {Page 2}
39 {Page 3} Dx: Colloid cyst
40 Cerebellar Astrocytoma G 53-55
41 Case 5 History: 50 y/o female with acute onset of headache & confusion
42 {Page 2} Dx: Herpes simplex encephalitis
43 Herpes Simplex Encephalitis Rapid course Temporal lobes, inferior frontal & insular cortex Cortical edema & mass effect Gyral enhancement Early therapy critical
44 Meningitis Organisms Bacteria Virus (meningoencephalitis) Tuberculosis Fungus Enhancement of basal cisterns Differential diagnosis Leptomeningeal seeding of tumor Encephalitis
45 History: 39 woman with SLE on chronic immunosuppression with steroids & methotrexate
46 {Page 2} Dx: TB meningitis
47 Newborn with low APGAR scores T2W T1W
48 {Page 2} DWI
49 History: 30 y.o. diabetic female was brought to the ED in a coma
50 Coma {Page 2} 2 days later Dx: Hypoglycemia Insulin overdose
51 Acute / Progressive Visual Deficit
52 Acute / Progressive Visual Deficit Monocular deficit Retinal detachment Ocular hemorrhage Mass compressing or stretching optic nerve Bitemporal hemianopsia Suprasellar mass Homonymous hemianopsia Stroke Mass compressing posterior visual pathways
53 Neuroradiological Workup Orbital ultrasound Globe & anterior compartment CT for orbit MRI is best overall
54 Case 6 History: 44 y.o. man with eye swelling, ophthalmoplegia & acute visual loss Question?
55 Which compartments of the orbit are involved by the disease? 1. Intraconal space 2. Extraconal space 3. Preceptal space 4. All of the above
56 {Page 2} Dx: Orbital cellulitis with SOF extension
57 History: 27 y/o woman with loss of vision in left eye Dx: Devic s disease
58 Case 11 History: 37 y/o man with headaches & decreased vision
59 {Page 2}
60 {Page 3} Dx: Hemorrhagic Pituitary adenoma
61 History: 49 y/o man with a visual deficits & lightheadedness p8145
62 {Page 2} Dx: Hippocampal infarct
63 Acute / Progressive Myelopathy
64 Acute / Progressive Myelopathy Epidural hemorrhage Epidural abscess Tumor Inflammatory diseases Ischemia Cervical or thoracic disk extrusion Imaging: MRI
65 Case 3 History: 40 y/o male with fever, back pain, and a T6 sensory level
66 Dx: Epidural abscess {Page 2}
67 Case 8 History: 35 y/o man with back pain & leg weakness
68 Dx: Staph osteomyelitis {Page 2}
69 History: 65 y/o woman with back pain & progressive leg weakness & gait problem for 2 months
70 Dx: Plasmacytoma {Page 2}
71 History: 32 y/o man with back pain Dx: Epidural lymphoma 557
72 UCSD Neuroradiology Teaching File Website URL -
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