Disclosure. + Outline. Case-based approach to neurological emergencies that might present to the ED

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1 Kathleen R. Fink, MD University of Washington 5 th Nordic Emergency Radiology Course May 21, 2015 Disclosure My spouse receives research salary support from: Bracco BayerHealthcare Guerbet Outline Case-based approach to neurological emergencies that might present to the ED 1. Solitary enhancing mass 2. Multiple enhancing masses 3. Lobar white matter-predominant lesion 4. Hydrocephalus 1

2 Scenario 1 Solitary enhancing mass 59 yo woman, headache, dyscoordination 59 yo woman, headache FLAIR T1 T1 Post DWI 2

3 Lung cancer metastasis Ring enhancing mass at gray-white junction Half are solitary 30% three or more LOOK FOR ADDITIONAL LESIONS! 80% supratentorial Lung cancer metastasis Clues to histology: Melanoma may be T1 hyperintense Hemorrhagic: Lung Breast Melanoma Renal Cell Choriocarcinoma Thyroid Cancer Ddx: 46 yo man, worst HA of life Pre Post 3

4 46 yo man, worst HA of life T1 T1 Post 46 yo man, worst HA of life FLAIR T2* DWI WHO IV Glioblastoma Ring enhancing mass Solitary lesion (usually) /- hemorrhage Irregular enhancement Surrounding edema Vasogenic/infiltrative May see high DWI NOT light bulb bright Age 40s-60s 4

5 Ddx: 38 yo woman, 6 weeks HA, N/V Pre Post 38 yo woman, 6 weeks HA, N/V T1 T1 Post FLAIR 38 yo woman, 6 weeks HA, N/V DWI ADC 5

6 Pyogenic Abscess Ring enhancing mass Thick solid enhancement Capsule thinnest toward ventricle Daughter nodules Low T2 rim Light bulb bright DWI Of central necrotic core Dark ADC Complications: Ventriculitis Ventriculitis: Ependymal enhancement Layering debris in ventricle Actively evaluate for this finding which may be subtle! Ddx: 85 year old, somnolent 6

7 85 year old, somnolent T1 T1 Post FLAIR 85 year old, somnolent DWI ADC Primary CNS lymphoma Clues: Hyperdense CT Restricted diffusion (ADC values higher than abscess) Mild surrounding edema CT Immunocompetent Hyperdense Immunocompromise d May see hemorrhage or necrosis T1 Homogeneous Iso to hypointense T2/FL AIR T1 post Homogeneous Strong homogeneous enhancement toothpaste Central necrosis or hemorrhage Peripheral enhancement OR homogeneous enhancement 7

8 Scenario 1: Mass Lesion Differential diagnosis: Primary glial neoplasm WHO II: Nonenhancing Astrocytoma Oligodendroglioma Mixed WHO III Anaplastic WHO IV Glioblastoma Metastasis Multiple Abscess Lightbulb bright DWI Lymphoma Dense on CT /- somewhat bright DWI Tumefactive demyelination Subacute enhancing infarct Subacute hemorrhage Scenario 2 Multiple enhancing masses Ddx: 59 yo woman, headache 8

9 59 yo woman, headache FLAIR T1 Post T1 Post Multiple metastasis Ring enhancing mass at gray-white junction Half are solitary 30% three or more LOOK FOR ADDITIONAL LESIONS! 80% supratentorial May be hemorrhagic 23 yo with LUE tingling FLAIR T1 T1 Post 9

10 Corpus callosum Periventricular Subcortical Brainstem Active Demyelination In this case, Multiple Sclerosis. Multiple T2/FLAIR lesions Enhancement indicates active demyelination MS is a clinical diagnosis. MR findings supportive of MS dxs: Dissemination in space: Periventricular Juxtacortical Posterior fossa Spine Dissemination in Time: New lesion New enhancement ANN NEUROL 2011;69: Active Demyelination Differential Diagnosis: ADEM: Acute disseminated encephalomyelitis Appearance can be identical to MS Monophasic: All lesions are the same age. Usually children Occurs after respiratory infection Lacunar infarctions: Subacute infarcts enhance 10

11 Ddx: 41 year old, HIV. Blurry vision, unsteadiness, headache x 2 days In this setting, the ACR appropriateness criteria lists MRI as being In this setting, the ACR appropriateness criteria lists MRI as being most appropriate 11

12 41 year old, HIV. Blurry vision, unsteadiness, headache x 2 days HIV patient with neuro symptoms: Strongly consider MRI Toxoplasmosis Immunocompromised patient Multiple ring enhancing lesions Basal ganglia Thalamus Cortex Eccentric target sign Surrounding edema NO restricted diffusion Resolve with treatment Differential diagnosis: Cryptococcus: Dilated VR spaces Tuberculosis: associated basilar meningitis 45 yo, seizure DWI 12

13 45 yo, seizure FLAIR FLAIR T1 Post MR 3 weeks later FLAIR MR 3 weeks later T1 T1 Post T1 Post 13

14 Septic emboli IVDA, Bacterial endocarditis May manifest as: -Bland infarcts -Abscesses -Mycotic aneurysms Initially, resemble bland emboli Vasogenic edema more prominent May hemorrhage Clinical history important! Scenario 2: Multiple enhancing lesions Differential diagnosis: Metastases Multifocal Glioblastoma Demyelinating lesions Septic emboli Subacute (bland) infarcts Abscess Pyogenic Neurocysticercosis Toxoplasmosis (immunocompromised) Fungal (immunocompromised) Multiple pyogenic abscesses Scenario 3 Lobar white matter predominant lesions 14

15 59 yo, lymphoma, seizure FLAIR DWI was normal. PRES Posterior reversible encephalopathy syndrome Vasogenic edema: Occipital, parietal lobes Posterior temporal lobes Posterior frontal lobes Cerebellum Unusual but reported: brainstem Thalamus, caudate Can show restricted diffusion Hemorrhage in 15% Reverses on follow up Patients at risk: -Post transplant -Infection/sepsis/shock -Eclampsia -Cyclosporine FK 506 toxicity -Hypertension -et cetera Hefzy, AJNR

16 FLAIR On presentation 1 month later Not to be confused with: 66 year old, headache for four days Rapidly declined in ED to coma Comatose on transfer 16

17 Basilar tip thrombosis with infarct. All areas of abnormality demonstrate restricted diffusion. Gray and white matter involved In this case, there was basilar tip thrombosis on CTA and MRA (not shown) Ddx: 43 yo man, gait disturbance T1 T1 post 43 yo man, gait disturbance T2 DWI 17

18 HIV: PML Progressive multifocal leukoencephalopathy JC virus Rapid progressive neuro deficits Imaging Increased T2 in WM, asymmetric, occipital and parietal lobes Extends to subcortical U fibers No mass effect Tends to not enhance No restricted diffusion Ddx: 24 year old, seizure HSV encephalitis CT: Low attenuation in temporal lobe and insula Petechial hemorrhage Delayed calcifications MRI: Increased T2 in mesial temporal lobes, cingulate gyri, inferior frontal lobes Variable enhancement May see petechial hemorrhage Early treatment key! May reduce temporal lobe injury and subsequent seizures. 18

19 Scenario 3: White matter lesion Differential diagnosis: Infarct -Venous -Arterial (look for gray matter involvement) PRES Triggers PML HIV HSV Young person with seizure Scenario 4 Hydrocephalus 24 year old with photophobia and nausea and vomiting. IVDU 19

20 24 year old with photophobia and nausea and vomiting. IVDU Basilar Meningitis Hydrocephalus in young person: Neurosurgical emergency! MR demonstrates enhancing basilar material. Ddx, basilar meningitis: TB meningitis Neurosarcoidosis Meningeal carcinomatosis Coccidioidomycosis Cryptococcus Basilar meningitis parenchymal lesions Think TB! History: 19 year old with worsening headache, nausea, and vomiting. 20

21 Additional images Flair T1 post Tuberculous meningitis Basilar meningitis: Can present with hydrocephalus due to thick inflammatory exudate Intracranial tuberculoma Granulomatous lesions Caseating or noncaseating /- necrotic center Tuberculous abscess MRS: Prominent lipid/lactate peak. No amino acid peaks Complications: Vasculitis, infarcts Patkar Neuroimaging Clin N Am 22:4, Key Imaging Features CT normal or HCP CT normal or HCP CT Normal Hydrocephalus Isodense exudate in basilar cisterns MR Enhancing basilar leptomeninges Infarcts Tuberculomas: Solid, nodular or ring enhancement 21

22 Tuberculous meningitis DWI Complications: Infarcts T1 post Ddx: 79 year old, heparin gtt Posterior fossa mass 22

23 23 yo, headache FLAIR 23 yo, headache T1 T2 Colloid cyst Mucin containing third ventricular cyst at foramen of Monro CT density variable MR signal variable. No enhancement or thin rim enhancement. Ddx: Flow artifact Usually pathognomonic appearance 23

24 Central volume loss Ventricular dilatation Sulcal widening No evidence of periventricular CSF transudation No basilar cisternal effacement. Volume loss in HIV disease Scenario 4: Hydrocephalus Differential diagnosis: Acute: Basilar meningitis Colloid Cyst Posterior fossa mass SAH Chronic Volume loss (not true HCP) NPH (clinical diagnosis) Posterior fossa mass Aqueductal stenosis Outline Case-based approach to neurological emergencies that might present to the ED 1. Solitary enhancing mass 2. Multiple enhancing masses 3. Lobar white matter-predominant lesion 4. Hydrocephalus 24

25 Thank you! Kathleen Fink The Seattle skyline as seen from Seacrest park in West Seattle. Sunset on Friday January 3rd, Photo by Katherine B. Turner 25