Non-Traumatic Neuro Emergencies

Transcription

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 -