Department of Radiology University of California

San Diego

John R. Hesselink, M.D.

Non-Traumatic Neuro Emergencies

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

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Dx: Infarct & MCA stenosis

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DWI

ADC

History: 32 y/o woman with headache, confusion & right sided weakness

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Case 1

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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

Dx: Thrombosis of superior sagittal sinus, left transverse sinus & deep venous system

Confusion & weakness {Page 3}

Venous / Sinus Occlusion

Hypercoagulable state Pregnancy Sepsis Dehydration Paranasal sinus or mastoid infection Neoplastic invasion

Causes

History: 59 y/o woman with headache and left-sided weakness

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Case 2

Weakness {Page 2}

T1 - FATSAT

1

2

3 T2W

Dx: Right ICA dissection

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History: 43 y/o man with sudden onset of right face & arm weakness

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Case 4

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Dx: Hyperacute hemorrhage & AVM

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Question?

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

Aneurysm

AV Malformation

Other

Other causes: bleeding into tumor, hypocoagulable state, hemorrhagic infarction and iatrogenic

36%

11%

17%

36%

History: 5 y/o girl with seizures

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Case 10

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Diffusion image

Question?

How does the DWI image help in differential diagnosis?

1. Indicates hemorrhage

2. Excludes a bacterial abscess

3. Excludes toxoplasmosis

4. Favors a tumor

Dx: Amoebic abscesses

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Pyogenic Brain Abscess

Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece

Acetate

Alanine

Lactate

Cytosolic Acid

“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

Dx: p-comm aneurysm

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History: 45 y/o female with severe headache

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Case 9

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Dx: SAH due to bilobed basilar tip aneurysm

Headache {Page 3}

History: 54 y.o. man with severe

headache

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Dx: Cocci meningitis

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“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

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History: 34 y/o man with intermittent chronic headaches & acute decreased mental status

Case 7

Headaches {Page 2}

Dx: Colloid cyst

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Cerebellar Astrocytoma

G 53-55

History: 50 y/o female with acute onset of headache & confusion

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Case 5

Dx: Herpes simplex encephalitis

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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

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Dx: TB meningitis

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Newborn with low APGAR scores

T1W

T2W

1

2

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2

DWI

History: 30 y.o. diabetic female was brought to the ED in a coma

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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

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History: 44 y.o. man with eye swelling, ophthalmoplegia & acute visual loss

Case 6

Question?

Which compartments of the orbit are involved by the disease?

1. Intraconal space

2. Extraconal space

3. Preceptal space

4. All of the above

Dx: Orbital cellulitis with SOF extension

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Dx: Devic’s disease

History: 27 y/o woman with loss of vision in left eye

History: 37 y/o man with headaches & decreased vision

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Case 11

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Dx: Hemorrhagic Pituitary adenoma

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History: 49 y/o man with a visual deficits & lightheadedness

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Dx: Hippocampal infarct

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“Acute / Progressive

Myelopathy”

Acute / Progressive Myelopathy

Epidural hemorrhage Epidural abscess Tumor Inflammatory diseases Ischemia Cervical or thoracic disk extrusion Imaging: MRI

History: 40 y/o male with fever, back pain, and a T6 sensory level

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Case 3

Dx: Epidural abscess

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History: 35 y/o man with back pain & leg weakness

Case 8

Dx: Staph osteomyelitis

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History: 65 y/o woman with back pain & progressive leg weakness & gait problem for 2 months

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Dx: Plasmacytoma

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Dx: Epidural lymphoma

History: 32 y/o man with back pain

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UCSD Neuroradiology Teaching File Website

URL - http://spinwarp.ucsd.edu/NeuroWeb/