imaging neurologic emergencies · emergency department reporting a several hour history of...
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Imaging Neurologic Emergencies:Imaging Neurologic Emergencies:When and Where Radiology Makes a DifferenceWhen and Where Radiology Makes a Difference
James G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.Radiology and Radiological SciencesRadiology and Radiological Sciences
Uniformed Services UniversityUniformed Services UniversityBethesda, MDBethesda, MD
Learning ObjectivesLearning Objectives
Choose the best imaging for each patientChoose the best imaging for each patient
Develop a Develop a ““checklistchecklist”” for imaging to for imaging to improve your ability to identify significant improve your ability to identify significant findingsfindings
Recognize imaging findings that will Recognize imaging findings that will acutely change patient managementacutely change patient management
Clinical Assessment
History– Headache, Seizure, Weakness, Visual– Traumatic, non-trauma, “found down”
Level of Consciousness– Glasgow Coma Scale (GCS)
Neurologic Examination– Cranial Nerve Exam (CNN 2-12)– Extremities – moving all four?
Imaging Assessment
What tests are on the “menu”?– CT scans
w/o contrastwith contrast
– MR scansw/o contrastwith contrast“Special” MR (e.g. Diffusion, Perfusion, etc.)
What test should I get?– Almost always a non-contrast CT scan
Imaging Assessment
What should I look for?– Global Assessment for abnormalities– Mass Effect, Brain Shift or Herniation– BWH?
Diagnosis and Etiology– Traumatic– Non-Traumatic
Vascular (e.g. “stroke”)Toxic/MetabolicNeoplastic
Treatment Decisions– Surgical vs. “Conservative” or “Medical Management”
MR and CT Imaging ChecklistsMR and CT Imaging Checklists
Anatomic LocationsAnatomic Locations–– SagittalSagittal ImagesImages
Sup. Sag. SinusSup. Sag. SinusCorpus CallosumCorpus CallosumSellaSella RegionRegionClivusClivus
–– Axial ImagesAxial ImagesSkull, Skull, EpiEpi/Sub Dural/Sub DuralSASSASCortical Gray MatterCortical Gray MatterWhite MatterWhite MatterDeep Gray MatterDeep Gray MatterVentriclesVentricles
Morphologic FeaturesMorphologic Features–– Mass EffectMass Effect
Yes, proportionalYes, proportionalLess than expectedLess than expectedNo mass effectNo mass effect
–– Abnormal WM SignalAbnormal WM SignalVasogenic EdemaVasogenic EdemaDemyelinationDemyelinationInfiltrating neoplasmInfiltrating neoplasm
–– Enhancing Ring LesionEnhancing Ring LesionNecrotic NeoplasmNecrotic NeoplasmReactive (e.g. abscess)Reactive (e.g. abscess)Fluid or InflammatoryFluid or Inflammatory
History of Imaging Acute CNS
AutopsySkull series plain filmsAngiography– Gross mass lesions (EDH, SDH)
Computed Tomography– EDH, SDH, Contusion, some DAI
Conventional Spin Echo MRI– More of the above
GRE/MSI, DTI, MRS, fMRI– Even more
CNN 2: BlindnessCNN 2: Blindness
45 45 y.oy.o. man with acute onset of right. man with acute onset of right--sided sided homonymous hemianopsiahomonymous hemianopsia
Where would the lesion be?
L R
LR
What we see What we see -- FindingsFindings
Axial CTAxial CTAbnormal Cortex and WMAbnormal Cortex and WM–– Where?Where?
Medial Occipital LobeMedial Occipital Lobe
–– Minimal mass effectMinimal mass effect
Right Homonymous Hemianopsia:What the Patient Sees …
L R
L R
NonNon--Contrast CTContrast CT
PCA InfarctPCA Infarct
Lights up like a lightbulbon MRI DWI
Post. Cerebral A. InfarctPost. Cerebral A. Infarct
Imaging InfarctionImaging Infarction
CT abnormal in hoursCT abnormal in hoursMR abnormal in minutesMR abnormal in minutesInsular ribbon signInsular ribbon sign–– Increased waterIncreased water
Hyperdense MCAHyperdense MCAHyperintense MCAHyperintense MCAVascular (intravascular) enhancementVascular (intravascular) enhancement
DWI BrightDWI BrightADC DarkADC Dark
Intraluminalclot
Intracellular Cytotoxic Edema
Carotid Thrombosis => Carotid Thrombosis => MCA ClotMCA Clot
MCAACA
MCA
PCA
X
medpix20366.jpgThis 53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body weakness
Repeat CT scans, two hours after admission
Repeat CT: Hyperdense MCARepeat CT: Hyperdense MCA
DWI
Restricted Diffusion – or T2 Shine-
Thru?ADC Map
Matching DWI and ADC Images = Matching DWI and ADC Images = CytotoxicCytotoxic Edema = Acute InfarctEdema = Acute Infarct
CytotoxicCytotoxic EdemaEdema
Normal Na+ Normal Na+ K+ K+ pumppump–– K goes InK goes In–– Na goes OutNa goes Out
Energy DependentEnergy Dependent–– GlucoseGlucose–– O2O2–– ATPATP
Normal Neuron
Swollen Dead Neuron
Chronic Infarct
Atrophy
Two days after IA Thrombolysis
Complications of Complications of rTPArTPA
Whole MCA InfarctionWhole MCA Infarction
Acute Motor Acute Motor HemiplegiaHemiplegia
BP on presentation 185/105
Courtesy Doug Phillips, UVA
INTRAINTRA--CEREBRAL HEMORRHAGECEREBRAL HEMORRHAGEDense and HomogeneousDense and HomogeneousRound/oval shapeRound/oval shapeBasal ganglia/deep whiteBasal ganglia/deep whiteProportional mass effectProportional mass effectExtension into ventricleExtension into ventricle
Hypertensive HemorrhageHypertensive Hemorrhage
BP on presentation 210/110
Courtesy Doug Phillips, UVA
Hypertensive HemorrhageHypertensive Hemorrhage
Hypertensive “hit list”Basal GangliaInternal/External CapsuleThalamusDentate NucleusPonsLobar
Courtesy Doug Phillips, UVA
HeadacheHeadache
39 39 y.oy.o. woman with abrupt onset of the . woman with abrupt onset of the ““worst headache of my lifeworst headache of my life””
What we see What we see -- FindingsFindings
Axial CTAxial CTAbnormalAbnormalWhere?Where?–– Subarachnoid spaceSubarachnoid space
How?How?–– HyperdenseHyperdense
Worst HA: NonWorst HA: Non--Contrast CTContrast CT
Aneurysm and RuptureAneurysm and Rupture
Clinical Clinical HxHx::–– "Worst Headache of My Life"Worst Headache of My Life””–– NuchalNuchal RigidityRigidity–– PhotophobiaPhotophobia
Signs: Signs: KernigKernig’’ss, , Brudzinski'sBrudzinski'sDemographics:Demographics:–– Common Cause of Stroke in Young (< 40)Common Cause of Stroke in Young (< 40)–– Most pts. 40Most pts. 40--60yrs60yrs
Risk Factors: Hypertension, ADPCKD, CTD Risk Factors: Hypertension, ADPCKD, CTD (connective tissue)(connective tissue)
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Subarachnoid HemorrhageSubarachnoid Hemorrhage
LP more sensitive than CTLP more sensitive than CTTrauma is most common cause for RBCTrauma is most common cause for RBC’’S S in CSFin CSF–– Not seen as easily or as often on CTNot seen as easily or as often on CTSAH on CTSAH on CT–– Blood clotBlood clot–– usually Aneurysm / AVMusually Aneurysm / AVM–– Uncommon from neoplasmUncommon from neoplasm–– Uncommon from spinal diseaseUncommon from spinal disease
Subarachnoid ClotsSubarachnoid Clots
AneurysmAneurysm
Round (Round (‘‘berryberry’’) shape) shapeVessel bifurcationVessel bifurcation–– natural weaknessnatural weakness–– exploited by high BPexploited by high BP
Common sites:Common sites:–– ACA <ACA <--> ACOMM> ACOMM–– MCA branchesMCA branches–– Basilar TipBasilar Tip
Angiography Angiography -- AngiogramAngiogram
AP Oblique
ICA AneurysmICA Aneurysm
MRAT2WMR
Pulsation Artifact
Phase-encoding direction
ICA AneurysmICA Aneurysm
““Found DownFound Down””34 34 yoyo marine stationed at Guantanamo Bay Cuba, marine stationed at Guantanamo Bay Cuba,
presenting w/ acute mental status changes, febrile.presenting w/ acute mental status changes, febrile.
T2WMR
Abnormal Gray MatterAbnormal Gray Matter
VascularVascular–– IschemiaIschemia–– InfarctionInfarction–– Hyperemia (Migraine, Seizures)Hyperemia (Migraine, Seizures)
InflammatoryInflammatory–– EncephalitisEncephalitis–– MeningoMeningo--EncephalitisEncephalitis–– VasculitisVasculitis
Abnormal Gray MatterAbnormal Gray Matter
Vascular – Follows territory of MCA, etc.
Infection – Multiple territories
T2WMR
NonNon--Vascular Vascular »» HSV EncephalitisHSV Encephalitis
MCA
ACA
MCA
ACA
MCA
AChoA
ACA
PCA
34 34 yoyo comatose woman, psychiatric pt. comatose woman, psychiatric pt.
Courtesy Aimee Hawley, M.D. MGAFMC
FindingsFindings
IntraaxialIntraaxialDiffuse Bilateral abnormalitiesDiffuse Bilateral abnormalities–– Low attenuation in Cortical Gray MatterLow attenuation in Cortical Gray Matter–– Low attenuation in Basal GangliaLow attenuation in Basal Ganglia
““EdemaEdema””–– What Kind?What Kind?
InterstitialInterstitialCytotoxicCytotoxicHydrostaticHydrostatic
Toxic/MetabolicToxic/Metabolic
Lab: Serum Na+ 121Lab: Serum Na+ 121
Psychogenic Psychogenic polydipsiapolydipsiaOverhydrationOverhydration–– Athletes drinking too much waterAthletes drinking too much water
IatrogenicIatrogenic–– D5W w/o saltsD5W w/o salts
TreatmentTreatment–– Hypertonic SalineHypertonic Saline–– 2% saline (not 4%)2% saline (not 4%)
Causes of Causes of HyponatremiaHyponatremia
Increased total body waterIncreased total body water–– Excessive water intakeExcessive water intake–– Iatrogenic (IV therapy)Iatrogenic (IV therapy)
Reduced Urine OutputReduced Urine Output–– ExerciseExercise–– Heat ExposureHeat Exposure–– Inappropriate ADHInappropriate ADH
Sodium LossSodium LossInadequate Sodium IntakeInadequate Sodium Intake
Treatment:
Correction by administration of IV Saline, or twice normal, or …
Treatment of Treatment of HyponatremiaHyponatremia
Rapid Correction of serum Na+Rapid Correction of serum Na+
T1W
T2W
DWI
Osmotic Osmotic MyelinolysisMyelinolysis
What do they have in Common?What do they have in Common?
MultipleMultipleBilateralBilateralSymmetricSymmetricAnatomicAnatomicBasal gangliaBasal ganglia
Toxic and/or Metabolic:
•Acquired
•Congenital
MetabolicMetabolic
IntrinsicIntrinsicDiabetic Diabetic KetoacidosisKetoacidosisHypoglycemic ComaHypoglycemic Coma
ExtrinsicExtrinsicToxic ExposuresToxic ExposuresCO and MethanolCO and Methanol
Carbon Monoxide Methanol Intoxication
Medial vs. Lateral LenticularMedial vs. Lateral Lenticular
Carbon Monoxide Methanol Intoxication
Medial vs. Lateral LenticularMedial vs. Lateral Lenticular
CO PoisoningCO Poisoning
Carbon Monoxide IntoxicationCarbon Monoxide Intoxication
CO IntoxicationCO Intoxication
CO binds to CO binds to HgbHgb 240X stronger than O240X stronger than O22making making carboxyhemoglobincarboxyhemoglobinSxSx: HA, Lethargy, weakness, dizziness, : HA, Lethargy, weakness, dizziness, nausea, confusion, and SOB nausea, confusion, and SOB TX is to displace CO with OTX is to displace CO with O22–– TT1/21/2 for CO is 320 min on room airfor CO is 320 min on room air–– 80 min on 100% O80 min on 100% O22
–– 23 min at 3 23 min at 3 atmatm 100% O100% O22
MetOHMetOH IntoxicationIntoxication
TxTx for for MetOHMetOH -- FomepazoleFomepazoleFomepazoleFomepazole ((AntizoleAntizole, 4, 4--methylperazole) is a methylperazole) is a synthetic synthetic alcohol alcohol dehydrogenasedehydrogenase inhibitor inhibitor for IV administrationfor IV administrationClear yellow liquid, mw 82.1, mp 25Clear yellow liquid, mw 82.1, mp 25ºº C (77C (77ºº F)F)INDICATIONS: Antidote for ethylene glycol, or methanol INDICATIONS: Antidote for ethylene glycol, or methanol poisoning or suspected EG ingestionpoisoning or suspected EG ingestionPRECAUTIONS: Dilute in > 100 PRECAUTIONS: Dilute in > 100 mLmL NS, follow NS, follow hepatic enzymes & WBC (hepatic enzymes & WBC (eoseos) during Rx, ) during Rx, interaction with ethanol (compete for ADH)interaction with ethanol (compete for ADH)DOSE: 15 mg/kg load, 10 mg/kg Q 12 h DOSE: 15 mg/kg load, 10 mg/kg Q 12 h xx 4 doses, 4 doses, then 15 mg/kg Q 12 h till EG < 20 mg/then 15 mg/kg Q 12 h till EG < 20 mg/dLdL
Anoxia During SurgeryAnoxia During Surgery
Diffuse and Bilateral Gray-matter hypointensities
Anoxia During SurgeryAnoxia During Surgery
Diffuse and Bilateral Gray-matter hypointensities
What we saw What we saw ……
TraumaTrauma–– Epidural Hematoma => Brain HerniationEpidural Hematoma => Brain Herniation–– Subdural Hematoma => Brain HerniationSubdural Hematoma => Brain HerniationVascular Vascular –– Acute Cerebral InfarctionAcute Cerebral Infarction–– Spontaneous Spontaneous ““hypertensivehypertensive”” HematomaHematoma–– SAH from Ruptured Cerebral AneurysmSAH from Ruptured Cerebral AneurysmInfectionInfection–– Herpes EncephalitisHerpes EncephalitisMetabolic/ToxicMetabolic/Toxic–– HyponatremiaHyponatremia–– CO and CO and MetOHMetOH ToxicityToxicity
SummarySummary
Brain HerniationBrain Herniation–– EpiduralEpidural–– SubduralSubdural
TraumaTrauma–– Ventricular bloodVentricular blood–– Shearing InjuryShearing Injury
Gray matterGray matter–– EncephalitisEncephalitis–– Ischemia/InfarctionIschemia/Infarction
Toxic/MetabolicToxic/Metabolic–– Co vs. MethanolCo vs. Methanol
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Thank You!Thank You!Muito ObrigadoEUXAPIΣTΩ !
Mahalo !Dank u wel !
Merci BeaucoupDanke Schön !
Go Raimh Maith Agat
Mil Gracias