Department of Radiology University of California San Diego Non-Traumatic Neuro Emergencies John R. Hesselink, M.D.
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
Acute Focal Neurological Deficit
Acute Focal Neurological Deficit Arterial thrombosis, occlusion, dissection or embolus Brain hemorrhage Hypotension / Hypoxia Venous / sinus occlusion Cortical mass lesion
Neuroradiological Workup MR imaging T2WI & FLAIR GRE Diffusion T1WI with gadolinium MRA /MRV Angiography Diagnosis Thrombolysis Angioplasty
History: 47 y/o man with von-hippel-lindau disease & new left arm weakness 486-1959187
{Page 2} DWI ADC Dx: Infarct & MCA stenosis
Case 1 History: 32 y/o woman with headache, confusion & right sided weakness 355-1554979
{Page 2} Question?
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
Confusion & weakness {Page 3} Dx: Thrombosis of superior sagittal sinus, left transverse sinus & deep venous system
Venous / Sinus Occlusion Causes Hypercoagulable state Pregnancy Sepsis Dehydration Paranasal sinus or mastoid infection Neoplastic invasion
Case 2 History: 59 y/o woman with headache and left-sided weakness 187-1406140
1 Weakness {Page 2} 2 T1 - FATSAT T2W 3
Dx: Right ICA dissection {Page 3}
History: 43 y/o man with sudden onset of right face & arm weakness Case 4 645-0911397
{Page 2}
{Page 3} Question? Dx: Hyperacute hemorrhage & AVM
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
Intracranial Hemorrhage Non-traumatic Hypertension 36% Aneurysm 36% 11% 17% Other AV Malformation Other causes: bleeding into tumor, hypocoagulable state, hemorrhagic infarction and iatrogenic
Case 10 History: 5 y/o girl with seizures 361-1835966
{Page 2} Question? Diffusion image
How does the DWI image help in differential diagnosis? 1. Indicates hemorrhage 2. Excludes a bacterial abscess 3. Excludes toxoplasmosis 4. Favors a tumor
{Page 3} Dx: Amoebic abscesses
Pyogenic Brain Abscess Lactate Alanine Cytosolic Acid Acetate Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece
Worst Headache of Life!!
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
History: 63 y/o man collapsed while preaching on Sunday 369
{Page 2} Dx: p-comm aneurysm
Case 9 History: 45 y/o female with severe headache 282-1748789
{Page 2}
Headache {Page 3} Dx: SAH due to bilobed basilar tip aneurysm
132-1600382 History: 54 y.o. man with severe headache
{Page 2} Dx: Cocci meningitis
Acute / Increasing Confusion and Obtundation
Acute / Increasing Confusion & Obtundation Obstructive hydrocephalus Brain stem or basal ganglia hemorrhage Brain herniation Encephalitis Meningitis Metabolic & toxic disorders Imaging: CT and MRI
Case 7 History: 34 y/o man with intermittent chronic headaches & acute decreased mental status 246-1736874
Headaches {Page 2}
{Page 3} Dx: Colloid cyst
Cerebellar Astrocytoma G 53-55
Case 5 History: 50 y/o female with acute onset of headache & confusion 540-2054429
{Page 2} Dx: Herpes simplex encephalitis
Herpes Simplex Encephalitis Rapid course Temporal lobes, inferior frontal & insular cortex Cortical edema & mass effect Gyral enhancement Early therapy critical
Meningitis Organisms Bacteria Virus (meningoencephalitis) Tuberculosis Fungus Enhancement of basal cisterns Differential diagnosis Leptomeningeal seeding of tumor Encephalitis
History: 39 woman with SLE on chronic immunosuppression with steroids & methotrexate 701 1480813
{Page 2} Dx: TB meningitis
Newborn with low APGAR scores T2W T1W 498-2007173
{Page 2} 1 1 2 2 DWI
History: 30 y.o. diabetic female was brought to the ED in a coma 108-1669246
Coma {Page 2} 2 days later Dx: Hypoglycemia Insulin overdose
Acute / Progressive Visual Deficit
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
Neuroradiological Workup Orbital ultrasound Globe & anterior compartment CT for orbit MRI is best overall
Case 6 History: 44 y.o. man with eye swelling, ophthalmoplegia & acute visual loss Question? 145-0681151
Which compartments of the orbit are involved by the disease? 1. Intraconal space 2. Extraconal space 3. Preceptal space 4. All of the above
{Page 2} Dx: Orbital cellulitis with SOF extension
History: 27 y/o woman with loss of vision in left eye Dx: Devic s disease
Case 11 History: 37 y/o man with headaches & decreased vision 541-2054553
{Page 2}
{Page 3} Dx: Hemorrhagic Pituitary adenoma
History: 49 y/o man with a visual deficits & lightheadedness 377 - p8145
{Page 2} Dx: Hippocampal infarct
Acute / Progressive Myelopathy
Acute / Progressive Myelopathy Epidural hemorrhage Epidural abscess Tumor Inflammatory diseases Ischemia Cervical or thoracic disk extrusion Imaging: MRI
Case 3 History: 40 y/o male with fever, back pain, and a T6 sensory level 423-0920959
Dx: Epidural abscess {Page 2}
Case 8 History: 35 y/o man with back pain & leg weakness 517-1844769
Dx: Staph osteomyelitis {Page 2}
History: 65 y/o woman with back pain & progressive leg weakness & gait problem for 2 months 656-2166583
Dx: Plasmacytoma {Page 2}
History: 32 y/o man with back pain Dx: Epidural lymphoma 557
UCSD Neuroradiology Teaching File Website URL - http://spinwarp.ucsd.edu/neuroweb/