Sie sind auf Seite 1von 20
Essentials of Neuroradiology James G. Smirniotopoulos, M.D. Uniformed Services University Bethesda, MD And Armed
Essentials of
Neuroradiology
James G. Smirniotopoulos, M.D.
Uniformed Services University
Bethesda, MD
And
Armed Forces Institute of Pathology
Washington, DC
2 y.o. with dilated pupil Midline Herniation: Subfalcial and Downward Transtentorial

2 y.o. with dilated pupil

Midline Herniation: Subfalcial and Downward Transtentorial
Midline Herniation: Subfalcial and Downward Transtentorial
EPIDURAL HEMATOMA Trauma -> fracture & concussion Tearing/stripping of both layers of dura away from
EPIDURAL HEMATOMA Trauma -> fracture & concussion Tearing/stripping of both layers of dura away from

EPIDURAL HEMATOMA

Trauma -> fracture & concussion Tearing/stripping of both layers of dura away from inner table Laceration of outer periosteal layer of dura Laceration of meningeal vessels Inner (meningeal dura) intact Blood between naked bone and dura NORMAL arterial pressure continues to dissect

vessels Inner (meningeal dura) intact Blood between naked bone and dura NORMAL arterial pressure continues to
Learning Objectives Recognize Urgent Lesions Understand Acute Traumatic Lesions Describe four types of herniation

Learning Objectives

Recognize Urgent Lesions Understand Acute Traumatic Lesions Describe four types of herniation Triage Acute Vascular Lesions Recognize Diffuse cerebral swelling

Lesions Describe four types of herniation Triage Acute Vascular Lesions Recognize Diffuse cerebral swelling
EPIDURAL HEMATOMA Significant trauma Fracture & concussion (l.o.c.) Lucid Interval pt Wakes Up 40% pts.

EPIDURAL HEMATOMA

Significant trauma Fracture & concussion (l.o.c.)

Lucid Interval

pt Wakes Up 40% pts.

Delayed neurologic Sx (hrs. Later) Herniation, coma and death

(l.o.c.) Lucid Interval pt Wakes Up 40% pts. Delayed neurologic Sx (hrs. Later) Herniation, coma and
Epidural Hematoma
Epidural Hematoma
Brain Herniation Syndromes f t t

Brain Herniation Syndromes

f t t
f
t
t
Four Types of Brain Herniation Transcalvarial – cerebral cortex Subfalcial – Cingulate Gyrus Transtentorial

Four Types of Brain Herniation

Transcalvarial – cerebral cortex Subfalcial – Cingulate Gyrus Transtentorial

Downward – Uncus and Temporal Lobe Upward – Vermis

Foramen Magnum – Tonsils and Medulla

Gyrus Transtentorial Downward – Uncus and Temporal Lobe Upward – Vermis Foramen Magnum – Tonsils and
Calvarial Herniation

Calvarial Herniation

Calvarial Herniation
Calvarial Herniation
Brain Herniation Syndromes f C t U M t Kernohan’s Notch: T T Cerebral peduncle
Brain Herniation Syndromes
f
C
t
U M
t
Kernohan’s Notch:
T
T
Cerebral peduncle
contralateral to the
mass lesion
f C t U M t T T
f
C
t
U M
t
T
T
Subfalcial and Transtentorial Left to Right Shift … Subfalcial herniation … Downward Transtentorial

Subfalcial and Transtentorial

Subfalcial and Transtentorial Left to Right Shift … Subfalcial herniation … Downward Transtentorial

Left to Right Shift … Subfalcial herniation … Downward Transtentorial

Subfalcial and Transtentorial Left to Right Shift … Subfalcial herniation … Downward Transtentorial
Complex Subdural Hematoma 1cm pineal shift, 3cm Right-to-Left shift and Subfalcial Herniation

Complex Subdural Hematoma

1cm pineal shift, 3cm Right-to-Left shift and Subfalcial Herniation
1cm pineal shift, 3cm Right-to-Left shift and Subfalcial
Herniation
Complex Subdural Hematoma 1cm pineal shift, 3cm Right-to-Left shift and Subfalcial Herniation
Dural Baffles: Falx and Tentorium f C t U M t T T
Dural Baffles: Falx and Tentorium
f
C
t
U M
t
T
T
Subfalcial Herniation

Subfalcial Herniation

Subfalcial Herniation
Subfalcial Herniation
SDH: Subfalcial Herniation
SDH: Subfalcial Herniation
Subfalcial Herniation Cingulate

Subfalcial Herniation Cingulate

Subfalcial Herniation Cingulate
Subfalcial Herniation Cingulate
SDH » Brain Herniation

SDH » Brain Herniation

SDH » Brain Herniation
SDH » Brain Herniation
SDH » Brain Herniation
SDH » Brain Herniation
Tentorial hiatus and Midbrain Superior Cerebellar a. Oculomotor nerve (CN3) Posterior Cerebral a. Temporal

Tentorial hiatus and Midbrain

Tentorial hiatus and Midbrain Superior Cerebellar a. Oculomotor nerve (CN3) Posterior Cerebral a. Temporal

Superior Cerebellar a. Oculomotor nerve (CN3) Posterior Cerebral a. Temporal Herniation

Compresses

Compresses

CN3

PCA

Cerebellar a. Oculomotor nerve (CN3) Posterior Cerebral a. Temporal Herniation Compresses Compresses CN3 PCA
PCA Infarct from Herniation
PCA Infarct from Herniation
Transtentorial Herniation The PCA is compressed between the uncus and midbrain
Transtentorial Herniation
Transtentorial Herniation

The PCA is compressed between the uncus and midbrain

Transtentorial Herniation The PCA is compressed between the uncus and midbrain
PCA Infarct Tentorial Herniation Courtesy Mauricio Castillo, M.D. UNC

PCA Infarct Tentorial Herniation

PCA Infarct Tentorial Herniation Courtesy Mauricio Castillo, M.D. UNC

Courtesy Mauricio Castillo, M.D. UNC

PCA Infarct Tentorial Herniation Courtesy Mauricio Castillo, M.D. UNC
Diffuse cerebral swelling Anoxic Damage Loss of Autoregulation “Commotio Cerebri” Secondary herniation

Diffuse cerebral swelling

Anoxic Damage Loss of Autoregulation “Commotio Cerebri” Secondary herniation Duret Hemorrhage

swelling Anoxic Damage Loss of Autoregulation “Commotio Cerebri” Secondary herniation Duret Hemorrhage
30 y.o. man after motor cycle crash with facial swelling and facial fractures. Acute alteration

30 y.o. man after motor cycle crash with facial swelling and facial fractures. Acute alteration in level of awareness.

No sulci, no cisterns, low-attenuation both temporal lobes, brainstem (mid- brain) hyperattenuating lesion.
No sulci, no cisterns, low-attenuation both temporal lobes, brainstem (mid-
brain) hyperattenuating lesion.
2525 y/oy/o manman fromfrom aa helicopterhelicopter crash.crash. UponUpon arrival,arrival, patientpatient waswas

2525 y/oy/o manman fromfrom aa helicopterhelicopter crash.crash. UponUpon arrival,arrival, patientpatient waswas intubatedintubated andand sedatedsedated

crash.crash. UponUpon arrival,arrival, patientpatient waswas intubatedintubated andand sedatedsedated
crash.crash. UponUpon arrival,arrival, patientpatient waswas intubatedintubated andand sedatedsedated
crash.crash. UponUpon arrival,arrival, patientpatient waswas intubatedintubated andand sedatedsedated
3 Reasons for Getting an MR CT fails to explain Pt’s Condition CT fails to

3 Reasons for Getting an MR

CT fails to explain Pt’s Condition

CT fails to explain Pt’s Condition

CT fails to explain Pt’s Condition

an MR CT fails to explain Pt’s Condition CT fails to explain Pt’s Condition CT fails
Duret Hemorrhages Downward displaced brainstem Kinks and compresses perforators Hemorrhagic Infarction

Duret Hemorrhages

Downward displaced brainstem Kinks and compresses perforators Hemorrhagic Infarction
Downward displaced
brainstem
Kinks and compresses
perforators
Hemorrhagic Infarction
AfterAfter reviewingreviewing thisthis CT,CT, whatwhat wouldwould youyou dodo nextnext ?? a.a. SuggestSuggest FLAIRFLAIR

AfterAfter reviewingreviewing thisthis CT,CT, whatwhat wouldwould youyou dodo nextnext ??

a.a. SuggestSuggest FLAIRFLAIR MRMR b.b. SuggestSuggest MagneticMagnetic SusceptibilitySusceptibility ImageImage (MSI(MSI oror SWI)SWI) c.c. SuggestSuggest DiffusionDiffusion WeightedWeighted MRMR d.d. MakeMake DiagnosisDiagnosis

e.e. a,a, b,b, andand cc areare ALLALL suggestedsuggested

WeightedWeighted MRMR d.d. MakeMake DiagnosisDiagnosis e.e. a,a, b,b, andand cc areare ALLALL suggestedsuggested
WeightedWeighted MRMR d.d. MakeMake DiagnosisDiagnosis e.e. a,a, b,b, andand cc areare ALLALL suggestedsuggested 5
Findings Intraventricular hemorrhage Torn Choroid Plexus Shearing Injury

Findings

Intraventricular hemorrhage Torn Choroid Plexus Shearing Injury
Intraventricular hemorrhage
Torn Choroid Plexus
Shearing Injury
ShearingShearing InjuryInjury MSI

ShearingShearing InjuryInjury

MSI
MSI
DeepDeep LesionsLesions -- TerminologyTerminology IntermediateIntermediate ContusionsContusions ShearingShearing

DeepDeep LesionsLesions -- TerminologyTerminology

IntermediateIntermediate ContusionsContusions ShearingShearing InjuryInjury DiffuseDiffuse WhiteWhite--mattermatter InjuryInjury (DWI)(DWI) DiffuseDiffuse AxonalAxonal InjuryInjury (DAI)(DAI)

DiffuseDiffuse WhiteWhite --mattermatter InjuryInjury (DWI)(DWI) DiffuseDiffuse AxonalAxonal InjuryInjury (DAI)(DAI)
ShearingShearing InjuryInjury

ShearingShearing InjuryInjury

ShearingShearing InjuryInjury
Corpus Callosum T2W SWI

Corpus Callosum

Corpus Callosum T2W SWI
Corpus Callosum T2W SWI
Corpus Callosum T2W SWI

T2W

SWI

Corpus Callosum T2W SWI
SHEARINGSHEARING INJURIESINJURIES DeepDeep lesionslesions High High Velocity Velocity (MVA) (MVA) Trauma Trauma

SHEARINGSHEARING INJURIESINJURIES

DeepDeep lesionslesions

HighHigh VelocityVelocity (MVA)(MVA) TraumaTrauma Acceleration/DecelerationAcceleration/Deceleration

EspeciallyEspecially CORONALCORONAL angularangular momentummomentum SideSide ImpactImpact (Running(Running aa RedRed Light)Light)

DoDo notnot requirerequire anan impactimpact oror Fx.Fx. ““SHEARINGSHEARING OFOF AXONSAXONS””

BreaksBreaks connectionsconnections ActualActual forceforce maymay bebe tensiontension

““SHEARINGSHEARING”” ofof SmallSmall WMWM VESSELSVESSELS

SmallSmall (petechial)(petechial) hemorrhageshemorrhages

SHEARINGSHEARING ”” ofof SmallSmall WMWM VESSELSVESSELS SmallSmall (petechial)(petechial) hemorrhageshemorrhages
DIFFUSEDIFFUSE AXONALAXONAL INJURYINJURY NeurologicNeurologic SxSx BeginBegin atat ImpactImpact SomeSome havehave

DIFFUSEDIFFUSE AXONALAXONAL INJURYINJURY

NeurologicNeurologic SxSx BeginBegin atat ImpactImpact SomeSome havehave ImmediateImmediate L.O.C.L.O.C. SomeSome havehave PersistentPersistent VegetativeVegetative StateState Pathology:Pathology:

focifoci ofof hemorrhagehemorrhage inin corpuscorpus callosum,callosum, brainstem,brainstem, etc.etc. axonaxon retractionretraction ballsballs (ARB)(ARB) LongLong--TermTerm Survivors:Survivors:

microglialmicroglial clustersclusters focifoci ofof demyelinationdemyelination

-- TermTerm Survivors:Survivors: microglialmicroglial clustersclusters focifoci ofof demyelinationdemyelination
Corpus Callosum Dense, compact, white matter, bundles of axons

Corpus Callosum

Corpus Callosum Dense, compact, white matter, bundles of axons

Dense, compact, white matter, bundles of axons

Corpus Callosum Dense, compact, white matter, bundles of axons
AxonAxon RetractionRetraction BallsBalls

AxonAxon RetractionRetraction BallsBalls

AxonAxon RetractionRetraction BallsBalls
DeepDeep LesionsLesions –– CoronalCoronal ForcesForces Angular momentum in the Coronal Plane: Running a Red Light

DeepDeep LesionsLesions –– CoronalCoronal ForcesForces

DeepDeep LesionsLesions –– CoronalCoronal ForcesForces Angular momentum in the Coronal Plane: Running a Red Light

Angular momentum in the Coronal Plane:

Running a Red Light … T-Bone the cars

–– CoronalCoronal ForcesForces Angular momentum in the Coronal Plane: Running a Red Light … T-Bone the
WM – Axonal Transection Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted

WM – Axonal Transection

WM – Axonal Transection Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted axolemma.

Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted axolemma.

WM – Axonal Transection Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted axolemma.
DiffuseDiffuse axonalaxonal injuryinjury (Magnetic(Magnetic Susceptibility)Susceptibility) TSE T2 T u r b o F L A

DiffuseDiffuse axonalaxonal injuryinjury (Magnetic(Magnetic Susceptibility)Susceptibility)

(Magnetic(Magnetic Susceptibility)Susceptibility) TSE T2 T u r b o F L A I R FLASH T2*

TSE T2

Turbo FLAIR

FLASH T2* TE: 15 ms

FLASH T2* TE: 35 ms

Ref. Parizel PM et al. Eur. Radiol. 1998; 8: 960-965

r b o F L A I R FLASH T2* TE: 15 ms FLASH T2* TE:
CorpusCorpus CallosumCallosum andand BGBG

CorpusCorpus CallosumCallosum andand BGBG

CorpusCorpus CallosumCallosum andand BGBG
DiffuseDiffuse AxonalAxonal InjuryInjury -- FLAIRFLAIR Thanks to Pam Schaefer

DiffuseDiffuse AxonalAxonal InjuryInjury -- FLAIRFLAIR

Thanks to Pam Schaefer
Thanks to Pam Schaefer
Trauma, Intraventricular Blood => MR CT SWI

Trauma, Intraventricular Blood => MR

Trauma, Intraventricular Blood => MR CT SWI
Trauma, Intraventricular Blood => MR CT SWI
Trauma, Intraventricular Blood => MR CT SWI

CT

SWI

Trauma, Intraventricular Blood => MR CT SWI
UnconsciousUnconscious PatientPatient -- CTCT Thanks to Pam Schaefer

UnconsciousUnconscious PatientPatient -- CTCT

UnconsciousUnconscious PatientPatient -- CTCT Thanks to Pam Schaefer

Thanks to Pam Schaefer

UnconsciousUnconscious PatientPatient -- CTCT Thanks to Pam Schaefer
DiffuseDiffuse AxonalAxonal InjuryInjury -- MSI MSI Thanks to Pam Schaefer

DiffuseDiffuse AxonalAxonal InjuryInjury -- MSIMSI

DiffuseDiffuse AxonalAxonal InjuryInjury -- MSI MSI Thanks to Pam Schaefer
DiffuseDiffuse AxonalAxonal InjuryInjury -- MSI MSI Thanks to Pam Schaefer

Thanks to Pam Schaefer

DiffuseDiffuse AxonalAxonal InjuryInjury -- MSI MSI Thanks to Pam Schaefer
Blindness 45 y.o. man with acute onset of homonymous hemianopsia

Blindness

45 y.o. man with acute onset of homonymous hemianopsia

Blindness 45 y.o. man with acute onset of homonymous hemianopsia
Non-Contrast CT
Non-Contrast CT
Imaging Infarction CT abnormal in hours MR abnormal in minutes Insular ribbon sign Increased water

Imaging Infarction

CT abnormal in hours MR abnormal in minutes Insular ribbon sign Increased water

Hyperdense MCA Hyperintense MCA

Vascular (intravascular) enhancement

MCA Hyperintense MCA Vascular (intravascular) enhancement Intraluminal clot DWI Bright ADC Dark Intracellular

Intraluminal

clot

DWI Bright ADC Dark

MCA Vascular (intravascular) enhancement Intraluminal clot DWI Bright ADC Dark Intracellular Cytotoxic Edema

Intracellular

Cytotoxic Edema

MCA Vascular (intravascular) enhancement Intraluminal clot DWI Bright ADC Dark Intracellular Cytotoxic Edema
Carotid Thrombosis => MCA Clot MCA ACA X MCA PCA

Carotid Thrombosis => MCA Clot

MCA ACA X MCA PCA
MCA
ACA
X MCA
PCA
What we see - Findings Axial CT Abnormal Cortex and WM Where? Medial Occipital Lobe

What we see - Findings

Axial CT Abnormal Cortex and WM

Where?

Medial Occipital Lobe

Minimal mass effect

What we see - Findings Axial CT Abnormal Cortex and WM Where? Medial Occipital Lobe Minimal
Early MCA stroke Insular Ribbon Sign
Early
MCA
stroke
Insular Ribbon Sign
PCA Infarct Lights up like a lightbulb on MRI DWI
PCA Infarct
Lights up like a lightbulb
on MRI DWI
Post. Cerebral A. Infarct

Post. Cerebral A. Infarct

Post. Cerebral A. Infarct
Repeat CT: Hyperdense MCA Repeat CT scans, two hours after admission
Repeat CT: Hyperdense MCA
Repeat CT scans, two hours after admission
Cytotoxic Edema Normal Na+ K+ pump K goes In Na goes Out Energy Dependent Glucose

Cytotoxic Edema

Normal Na+ K+ pump

K goes In Na goes Out

Energy Dependent

Glucose

O2

ATP

Normal Neuron Swollen Dead Neuron
Normal Neuron
Swollen Dead Neuron
medpix20366.jpg
medpix20366.jpg

This 53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body weakness

53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body
Matching DWI and ADC Images = Cytotoxic Edema = Acute Infarct Restricted Diffusion – or

Matching DWI and ADC Images = Cytotoxic Edema = Acute Infarct

Restricted Diffusion – or T2 Shine- Thru? DWI ADC Map
Restricted
Diffusion – or
T2 Shine-
Thru?
DWI
ADC Map
Matching DWI and ADC Images = Cytotoxic Edema = Acute Infarct Restricted Diffusion – or T2
Neuronal Swelling
Neuronal Swelling
Restricted Diffusion
Restricted Diffusion
Complications of rTPA Two days after IA Thrombolysis
Complications of rTPA
Two days after IA Thrombolysis
Acute Motor Hemiplegia BP on presentation 185/105 Courtesy Doug Phillips, UVA

Acute Motor Hemiplegia

Acute Motor Hemiplegia BP on presentation 185/105 Courtesy Doug Phillips, UVA

BP on presentation 185/105

Courtesy Doug Phillips, UVA

Acute Motor Hemiplegia BP on presentation 185/105 Courtesy Doug Phillips, UVA
Chronic Infarct Atrophy
Chronic Infarct
Atrophy
Whole MCA Infarction

Whole MCA Infarction

Whole MCA Infarction
INTRA-CEREBRAL HEMORRHAGE Dense and Homogeneous Round/oval shape Basal ganglia/deep white Proportional mass

INTRA-CEREBRAL HEMORRHAGE

Dense and Homogeneous Round/oval shape Basal ganglia/deep white Proportional mass effect Extension into ventricle

and Homogeneous Round/oval shape Basal ganglia/deep white Proportional mass effect Extension into ventricle
Hypertensive Hemorrhage Hypertensive “hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus
Hypertensive Hemorrhage Hypertensive “hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus

Hypertensive Hemorrhage

Hypertensive Hemorrhage Hypertensive “hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus

Hypertensive “hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus Pons Lobar

Courtesy Doug Phillips, UVA

“hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus Pons Lobar Courtesy Doug Phillips, UVA
Glioblastoma multiforme, WHO 4 Courtesy Doug Phillips, UVA

Glioblastoma multiforme, WHO 4

Glioblastoma multiforme, WHO 4 Courtesy Doug Phillips, UVA

Courtesy Doug Phillips, UVA

Glioblastoma multiforme, WHO 4 Courtesy Doug Phillips, UVA
Hypertensive Hemorrhage BP on presentation 210/110 Courtesy Doug Phillips, UVA

Hypertensive Hemorrhage

BP on presentation 210/110
BP on presentation 210/110

Courtesy Doug Phillips, UVA

Hypertensive Hemorrhage BP on presentation 210/110 Courtesy Doug Phillips, UVA
“Found Down” 68 year old man with confusion and acute hemiplegia. NOTE: Vasogenic Edema Courtesy

“Found Down”

68 year old man with confusion and acute hemiplegia.

“Found Down” 68 year old man with confusion and acute hemiplegia. NOTE: Vasogenic Edema Courtesy Doug

NOTE: Vasogenic Edema

Courtesy Doug Phillips, UVA

“Found Down” 68 year old man with confusion and acute hemiplegia. NOTE: Vasogenic Edema Courtesy Doug
“Found Down” 34 yo marine stationed at Guantanamo Bay Cuba, presenting w/ acute mental status

“Found Down”

34 yo marine stationed at Guantanamo Bay Cuba, presenting w/ acute mental status changes, febrile.

“Found Down” 34 yo marine stationed at Guantanamo Bay Cuba, presenting w/ acute mental status changes,
Abnormal Gray Matter Vascular Ischemia Infarction Hyperemia (Migraine, Seizures) Inflammatory Encephalitis

Abnormal Gray Matter

Vascular

Ischemia Infarction Hyperemia (Migraine, Seizures)

Inflammatory

Encephalitis Meningo-Encephalitis Vasculitis

Ischemia Infarction Hyperemia (Migraine, Seizures) Inflammatory Encephalitis Meningo-Encephalitis Vasculitis
Non-Vascular » HSV Encephalitis ACA ACA MCA MCA

Non-Vascular » HSV Encephalitis

ACA ACA MCA MCA
ACA
ACA
MCA
MCA
Non-Vascular » HSV Encephalitis ACA ACA MCA MCA Abnormal Gray Matter Vascular – Follows territory of
Abnormal Gray Matter Vascular – Follows territory of MCA, etc. Infection – Multiple territories
Abnormal Gray Matter
Vascular – Follows territory of MCA, etc.
Infection – Multiple territories
ACA MCA AChoA PCA
ACA
MCA
AChoA
PCA
HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis

HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
HSV encephalitis HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis

HSV encephalitis HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
HSV encephalitis HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis

Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
What do they have in Common? Multiple Bilateral Symmetric Anatomic Basal ganglia Toxic and/or Metabolic:

What do they have in Common?

Multiple

Bilateral

Symmetric

Anatomic

Basal ganglia

Toxic and/or Metabolic:

Acquired

Congenital

in Common? Multiple Bilateral Symmetric Anatomic Basal ganglia Toxic and/or Metabolic: • Acquired • Congenital
Metabolic Intrinsic Diabetic Ketoacidosis Hypoglycemic Coma Extrinsic Toxic Exposures CO and Methanol

Metabolic

Intrinsic

Diabetic Ketoacidosis Hypoglycemic Coma

Extrinsic Toxic Exposures CO and Methanol

Metabolic Intrinsic Diabetic Ketoacidosis Hypoglycemic Coma Extrinsic Toxic Exposures CO and Methanol
HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis

HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC

Courtesy Mauricio Castillo, M.D. UNC

HSV encephalitis Courtesy Mauricio Castillo, M.D. UNC
Toxic/Metabolic

Toxic/Metabolic

Toxic/Metabolic
Medial vs. Lateral Lenticular Carbon Monoxide Methanol Intoxication

Medial vs. Lateral Lenticular

Carbon Monoxide Methanol Intoxication
Carbon Monoxide
Methanol Intoxication
Carbon Monoxide Methanol Intoxication Medial vs. Lateral Lenticular
Carbon Monoxide
Methanol Intoxication
Medial vs. Lateral Lenticular
Carbon Monoxide Intoxication
Carbon Monoxide Intoxication
MetOH Intoxication

MetOH Intoxication

MetOH Intoxication
CO Poisoning

CO Poisoning

CO Poisoning
CO Intoxication CO binds to Hgb 240X stronger than O 2 making carboxyhemoglobin Sx: HA,

CO Intoxication

CO binds to Hgb 240X stronger than O 2 making carboxyhemoglobin Sx: HA, Lethargy, weakness, dizziness, nausea, confusion, and SOB TX is to displace CO with O 2

T 1/2 for CO is 320 min on room air 80 min on 100% O 2 23 min at 3 atm 100% O 2

to displace CO with O 2 T 1 / 2 for CO is 320 min on
Tx for MetOH - Fomepazole Fomepazole (Antizole, 4-methylperazole) is a synthetic alcohol dehydrogenase inhibitor for

Tx for MetOH - Fomepazole

Fomepazole (Antizole, 4-methylperazole) is a synthetic alcohol dehydrogenase inhibitor for IV administration Clear yellow liquid, mw 82.1, mp 25º C (77º F) INDICATIONS: Antidote for ethylene glycol, or methanol poisoning or suspected EG ingestion PRECAUTIONS: Dilute in > 100 mL NS, follow hepatic enzymes & WBC (eos) during Rx, interaction with ethanol (compete for ADH) DOSE: 15 mg/kg load, 10 mg/kg Q 12 h x 4 doses, then 15 mg/kg Q 12 h till EG < 20 mg/dL

(compete for ADH) DOSE: 15 mg/kg load, 10 mg/kg Q 12 h x 4 doses, then
3434 yoyo comatosecomatose woman,woman, psychiatricpsychiatric pt.pt. Courtesy Aimee Hawley, M.D. MGAFMC

3434 yoyo comatosecomatose woman,woman, psychiatricpsychiatric pt.pt.

3434 yoyo comatosecomatose woman,woman, psychiatricpsychiatric pt.pt. Courtesy Aimee Hawley, M.D. MGAFMC

Courtesy Aimee Hawley, M.D. MGAFMC

3434 yoyo comatosecomatose woman,woman, psychiatricpsychiatric pt.pt. Courtesy Aimee Hawley, M.D. MGAFMC
Diagnosis:Diagnosis: CytotoxicCytotoxic EdemaEdema CytotoxicCytotoxic EdemaEdema CerebralCerebral ischemiaischemia

Diagnosis:Diagnosis: CytotoxicCytotoxic EdemaEdema

CytotoxicCytotoxic EdemaEdema

CerebralCerebral ischemiaischemia MetabolicMetabolic PoisonsPoisons

CNCN TriethylTriethyl TinTin HexachlorpheneHexachlorphene

HypoglycemiaHypoglycemia

GrayGray mattermatter >> WhiteWhite mattermatter

TinTin HexachlorpheneHexachlorphene HypoglycemiaHypoglycemia GrayGray mattermatter >> WhiteWhite mattermatter
CausesCauses ofof HyponatremiaHyponatremia IncreasedIncreased totaltotal bodybody waterwater ExcessiveExcessive waterwater

CausesCauses ofof HyponatremiaHyponatremia

IncreasedIncreased totaltotal bodybody waterwater

ExcessiveExcessive waterwater intakeintake IatrogenicIatrogenic (IV(IV therapy)therapy)

ReducedReduced UrineUrine OutputOutput

ExerciseExercise HeatHeat ExposureExposure InappropriateInappropriate ADHADH

SodiumSodium LossLoss InadequateInadequate SodiumSodium IntakeIntake

Treatment:

Correction by administration of IV Saline, or twice normal, or …

SodiumSodium IntakeIntake Treatment: Correction by administration of IV Saline, or twice normal, or …
FindingsFindings IntraaxialIntraaxial DiffuseDiffuse BilateralBilateral abnormalitiesabnormalities Low Low attenuation

FindingsFindings

IntraaxialIntraaxial DiffuseDiffuse BilateralBilateral abnormalitiesabnormalities

LowLow attenuationattenuation inin CorticalCortical GrayGray MatterMatter LowLow attenuationattenuation inin BasalBasal GangliaGanglia

““EdemaEdema””

WhatWhat Kind?Kind?

InterstitialInterstitial

CytotoxicCytotoxic

HydrostaticHydrostatic

““ EdemaEdema ”” WhatWhat Kind?Kind? InterstitialInterstitial CytotoxicCytotoxic HydrostaticHydrostatic
““ EdemaEdema ”” WhatWhat Kind?Kind? InterstitialInterstitial CytotoxicCytotoxic HydrostaticHydrostatic
Lab:Lab: SerumSerum Na+Na+ 121121 PsychogenicPsychogenic polydipsiapolydipsia OverhydrationOverhydration

Lab:Lab: SerumSerum Na+Na+ 121121

PsychogenicPsychogenic polydipsiapolydipsia OverhydrationOverhydration

AthletesAthletes drinkingdrinking tootoo muchmuch waterwater

IatrogenicIatrogenic

D5WD5W w/ow/o saltssalts

TreatmentTreatment

HypertonicHypertonic SalineSaline 2%2% salinesaline (not(not 4%)4%)

D5WD5W w/ow/o saltssalts TreatmentTreatment HypertonicHypertonic SalineSaline 2% 2% saline saline (not (not 4%) 4%)
RapidRapid CorrectionCorrection ofof serumserum Na+Na+ T1W T2W DWI

RapidRapid CorrectionCorrection ofof serumserum Na+Na+

T1W T2W DWI
T1W
T2W
DWI
OsmoticOsmotic MyelinolysisMyelinolysis

OsmoticOsmotic MyelinolysisMyelinolysis

OsmoticOsmotic MyelinolysisMyelinolysis
AnoxiaAnoxia DuringDuring SurgerySurgery Diffuse and Bilateral Gray-matter hypointensities

AnoxiaAnoxia DuringDuring SurgerySurgery

AnoxiaAnoxia DuringDuring SurgerySurgery Diffuse and Bilateral Gray-matter hypointensities

Diffuse and Bilateral Gray-matter hypointensities

Diffuse and Bilateral Gray-matter hypointensities
Diffuse and Bilateral Gray-matter hypointensities
Diffuse and Bilateral Gray-matter hypointensities
What we see - Findings Axial CT Abnormal Where? Subarachnoid space How? Hyperdense

What we see - Findings

Axial CT Abnormal Where?

Subarachnoid space

How?

Hyperdense

What we see - Findings Axial CT Abnormal Where? Subarachnoid space How? Hyperdense
AnoxiaAnoxia DuringDuring SurgerySurgery Diffuse and Bilateral Gray-matter hypointensities

AnoxiaAnoxia DuringDuring SurgerySurgery

AnoxiaAnoxia DuringDuring SurgerySurgery Diffuse and Bilateral Gray-matter hypointensities

Diffuse and Bilateral Gray-matter hypointensities

Diffuse and Bilateral Gray-matter hypointensities
Diffuse and Bilateral Gray-matter hypointensities
Diffuse and Bilateral Gray-matter hypointensities
Headache 39 y.o. woman with abr upt onset of the “worst headache of my life”

Headache

39 y.o. woman with abrupt onset of the “worst headache of my life”

Headache 39 y.o. woman with abr upt onset of the “worst headache of my life”
Headache 39 y.o. woman with abr upt onset of the “worst headache of my life”
Worst HA: Non-Contrast CT

Worst HA: Non-Contrast CT

Worst HA: Non-Contrast CT
Aneurysm and Rupture Clinical Hx: "Worst Headache of My Life” Nuchal Rigidity Photophobia Signs: Kernig’s,

Aneurysm and Rupture

Clinical Hx:

"Worst Headache of My Life” Nuchal Rigidity Photophobia

Signs: Kernig’s, Brudzinski's Demographics:

Common Cause of Stroke in Young (< 40) Most pts. 40-60yrs

Risk Factors: Hypertension, ADPCKD, CTD (connective tissue)

Cause of Stroke in Young (< 40) Most pts. 40-60yrs Risk Factors: Hypertension, ADPCKD, CTD (connective
Subarachnoid Hemorrhage LP more sensitive than CT Trauma is most common cause for RBC’S in

Subarachnoid Hemorrhage

LP more sensitive than CT Trauma is most common cause for RBC’S in CSF

Not seen as easily or as often on CT

SAH on CT

Blood clot usually Aneurysm / AVM Uncommon from neoplasm Uncommon from spinal disease

or as often on CT SAH on CT Blood clot usually Aneurysm / AVM Uncommon from
Aneurysm / AVM Uncommon from neoplasm Uncommon from spinal disease Subarachnoid Hemorrhage Subarachnoid Clots 18
Subarachnoid Hemorrhage

Subarachnoid Hemorrhage

Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Aneurysm / AVM Uncommon from neoplasm Uncommon from spinal disease Subarachnoid Hemorrhage Subarachnoid Clots 18
Subarachnoid Clots

Subarachnoid Clots

Subarachnoid Clots
Aneurysm Round (‘berry’) shape Vessel bifurcation natural weakness exploited by high BP Common sites: ACA

Aneurysm

Aneurysm Round (‘berry’) shape Vessel bifurcation natural weakness exploited by high BP Common sites: ACA

Round (‘berry’) shape Vessel bifurcation

natural weakness exploited by high BP

Common sites:

ACA <-> ACOMM MCA branches Basilar Tip

bifurcation natural weakness exploited by high BP Common sites: ACA <-> ACOMM MCA branches Basilar Tip
ICA Aneurysm

ICA Aneurysm

ICA Aneurysm
ICA Aneurysm

ICA Aneurysm

ICA Aneurysm
ICA Aneurysm
Angiography - Angiogram Oblique AP

Angiography - Angiogram

Oblique AP
Oblique
AP
Pulsation Artifact Phase-encoding direction
Pulsation Artifact
Phase-encoding direction
Summary Brain Herniation f Epidural Subdural C Trauma Ventricular blood Shearing Injury Gray matter t
Summary
Brain Herniation
f
Epidural
Subdural
C
Trauma
Ventricular blood
Shearing Injury
Gray matter
t
U M
t
Encephalitis
Ischemia/Infarction
Toxic/Metabolic
Co vs. Methanol
T
T
Go Raimh Maith Agat Thank You! Muito Obrigado EUXAPI Σ T Ω ! Mahalo !

Go Raimh Maith Agat

Thank You!

Muito Obrigado

EUXAPIΣT!

Mahalo ! Dank u wel !

Merci Beaucoup

Danke Schön !

Mil Gracias

Maith Agat Thank You! Muito Obrigado EUXAPI Σ T Ω ! Mahalo ! Dank u wel