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Non-Traumatic Intracranial Emergencies

Non-Traumatic Intracranial Emergencies

Kevin Abrams, M.D.Chief of Radiology

Medical Director of Neuroradiology & MRIBaptist Hospital, Miami, FL

Themes

Diffuse Lesion: Infection vs Infarction Focal Lesion: Infection vs Tumor

Disclosures

I disclose that I serve as a consultant to Keystone Heart. My presentation will not include discussion of off-label or unapproved usage.

Diffuse: Infection vs Infarction

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NCCT

Basic Vascular Distributions

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PCA Infarct

Basic Vascular Distributions

PCA

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PCA

MCA

Ant Ch Art or MCA

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MCA Infarct Basic Vascular Distributions

Anterior Choroidal Art. Infarct

Next branch above pcom Besides choroid plexus supply,

important supply to uncus and post limb int. capsule

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Case 3

PCA Ant Ch Art

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64 yo male with crohns and dipolpia

4/19

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Several days before…

Invasive Fungal sinusitis aspergillosis

Invasive Fungal sinusitis aspergillosis

Case 4

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Herpes Encephalitis (Type I) A necrotizing encephalitis which is both

viral and indirect immune mediated that has a predilection for the medial temporal lobes, inferior frontal lobes, limbic system

Bimodal age dist. <20 (usu. primary 1/3) and >50(usu. latent reactivation 2/3) thru olfactory bulbs or trigeminal ganglia

Mortality: 70% if untreated; 19% if treated

Morbidity: 50% survivors have moderate to severe deficits

Early initiation of Rx (Acyclovir) is key for Px

Herpes Encephalitis (Type I) Symptoms: fever 90%, ha 80%, psy 70%,

sz 67%, focal weakness 33%, memory 24%

Imaging: swelling med. temp lobes, frontal bases, limbic system, insula. Cingulate gyrus; freq bilat, inc FLAIR, inc T2 DWI restricted, may be hemorrhagic, +/- enhancement

CSF: mono pleo, rbc’s, inc pro., PCR 96% sens., 98 % spec.

EEG: focal spike &slow or periodic sharp waves over temporal lobes.

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Insula + Medial Temporal Lobe= Herpes Encephalitis tpo

Insula + Medial Temporal Lobe= Herpes Encephalitis tpo

Herpes 2nd Case

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Herpes 3rd Case

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NCCT CECT

Case 5

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Limbic Encephalitis

First described in the 1960’s Autoimmune: Ab’s against 1. intracellular antigens:Hu (SLSC),

Ma2(testis nsclc), CV2/CRMP5(sclc, thymoma), amphiphysin, (breast, sclc) 2. cell mb anitgens: VGKC and NMDAR

(thymoma, ov dermoid)

Limbic encephalitis and variants, Tuzun etal, The Neurologist, vol 13 no.5, Sept 2007

Limbic Encephalitis Diag Crit. Paraneoplastic limbic

encephalitis: Path demonstration, OR All 4 of the following:

1.Short trm mem loss, sz, psy sx’s sugg limbic sys 2.<4 yr from onset of neuro sx’s and cancer dx 3.exclusion mets, infn, metabolic, stroke, side effects

of therapy 4. at least one of the following:

CSF with inflamm findings MRI flair or T2 uni or bilat temp lobe hyper EEG with epileptic or slow activity focally involving

temp lobes

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Case 6

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MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Initially described in 1984 Most commonly caused be A to G transition

mutation at position 3243 of the mitochondrial genome (inherited matrinlieally- mom only!)

Impairment of OXPHOS (multi-step process to generate ATP); shunt from pyruvate to lactate -> lactic acidosis

Clinical Syndrome: 1. stroke like syndrome before age 40; 2. encephalopathy sz’s &/or dementia; 3. lactic acidosis (serum or csf) &/or ragged red fibers

Stroke-like sx’s: episodes of partially reversible aphasia, hemianopsia, cortical blindness and eventual dementia

MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Imaging: temporal, parietal and occipital lobes

not respecting vasc territories. Mostly cortical but may involve adj. wm.; DWI bright but usu not restricted but can be. Lesions may fluctuate and go from side to side with eventual cortical atrophy. MRS: markedly elevated lactate. CT: B.G. Ca++

Other organ systems: muscles-exercise intolerance, cardiac- conduction (WPW) cardiomyopathy (concentric hypertrophy), endocrine- DM II, short stature, GI

Tx: no effective rx, ?CoQ10 other cocktails

MELAS, Sproule & Kaufmann, Ann NY Acad Sci 1142, 133-158 2008

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Case 7

Dka seizure disorderDka seizure disorder

Csf clean but strep in blood