CNS Pathology

Fall 2009
Final
INFLAMMATORY
DISEASE OF CNS
 Meningitis
1. Inflammation fo the meningeal coverings
of the brain and spinal cord

2. Can be caused by
1. Bacteria, virus and other organisms via
blood or lymph
2. Trauma, pentrating wounds or adjacent
structures infected

3. Bacterial is most common (can cause

hydrocephalus)
 Pathogens causing Meningitis
 ___________________
 Chronic meningitis
 Often associated with AIDS and immunodepressant drug therapy

 ___________________
 Viral meningitis can be caused by mumps, poliovirus and herpes
simplex

 ___________________
 Most common
 Bacteria release toxins that destroy meningeal cells stimulating
immune & inflammatory reactions
 Pathogens causing Meningitis
 Fungi
 Chronic meningitis
 Often associated with AIDS and immunodepressant drug therapy

 Virus
 Viral meningitis can be caused by mumps, poliovirus and herpes
simplex

 Bacteria
 Most common
 Bacteria release toxins that destroy meningeal cells stimulating
immune & inflammatory reactions
 Acute Meningitis
Clinical Symptoms

 Fever
 Headache
 Stiff neck
 Vomiting
 Changes in LOC
 Severely ill in 24 hours
 Rash
 Chronic symptoms are
the same but occur over
weeks
 Diagnosis of Meningitis
 Brain CT
 Rule out contraindications to do a spinal tap

 Spinal tap
 LP to remove CSF to send to lab

 Sometimes MRI is used

 Is most sensitive modality for demonstrating pia and

arachnoid

 Treatment includes:
 antibiotics and if secondary to encephalitis: antiviral

drugs
 Radiographic Appearance
 Initially meninges
show vascular
congestion, edema
and minute
hemorrhages

 MRI and CT scans

could appear normal
if appropriate therapy
is done right away Meningitis as a result of a Staph infection
 Encephalitis
 Infection of the brain tissue that is viral
 May occur subsequent to chickenpox, small
pox, influenza and measles
 May be caused by mosquitoes and herpes

 Survivalrates depend of cause of the

disease (can be fatal)
 30% of cases in children
 When caused by herpes it is often fatal
 Encephalitis
 MRI is modality of
choice

 Results in cerebral
edema and
hemorrhagic lesions

 More serious than

meningitis because it
frequently develops
permanent neurologic
disabilities
 Encephalitis:
Symptoms and Treatment
 Symptoms:  Treatment:
 Headache  Treated with antiviral
medications
 Malaise
 Herpes induced is
 Coma treated with Acyclovir
• Interferes with DNA
synthesis and inhibits
 Fever viral replication

 Seizures
 CONGENITAL
DISEASES OF CNS
 Spinal Bifida
 Is a congenital disease

 Bony neural arch that not completely closed

 Most common in lumbar region

 May or may not herniate through opening

 Can range in risk from treatable to life threatening

 Can be diagnosed in utero

 With amniocentesis
 Ultrasound
 Elevated beta fetoprotein in mother’s blood
 Types of Spinal Bifida
 ________________
 Only the meninges protrude
 Local defect of bone & dura

 ________________
 Protrusion of spinal cord
 ________________

 Protrusion of meninges and

spinal cord into the skin of the
back
 Most serious

 ________________
 No protrusion of spinal
contents
 Least severe
 Meningocele Types of
 Only the meninges


protrude
Local defect of bone & dura
Spinal Bifida
 Myelocele
 Protrusion of spinal cord

 Meningomelocele
 Protrusion of meninges and
spinal cord into the skin of
the back
 Most serious

 Spinal bifida occulta

 No protrusion of spinal
contents
 Least severe
 Radiographic Appearance
Meningomyelocele

 Can be demonstrated
with CT, MRI and
myelography
 Prenatally with
ultrasound (in utero)
Meningocele

 Large bony defects

 Herniated spinal
contents
 Meningomyelocele
 Most serious
 Affected PT’s have
severe neurologic
deficits
 Paraplegia
 Diminished control of
lower limbs, bladder
and bowels
 Hydrocephalus is
common
Spinal Bifida Imaging
 Spinal Bifida Treatment
 Can be surgically repaired
 Neurological damage is permanent still and cannot be
reversed

 Most measures are supportive rather than

corrective
 Physical therapy
 Physical supports
 Braces
 Splints
CRANIAL AND SPINAL
FRACTURES
 Cranial Fractures
 Cerebral fractures usually occurs to
fractures of the calvaria of the skull

3 types of cranial fractures

• _____________- straight and sharply defined
 Is 80% of all cranial fractures
• _____________- curvilinear density
• _____________- Air fluid levels are indicative
 Hard to diagnosis radiographically
 Cranial Fractures
 Cerebral fractures usually occurs to
fractures of the calvaria of the skull

3 types of cranial fractures

• Linear- straight and sharply defined
 Is 80% of all cranial fractures
• Depressed- curvilinear density
• Basilar- Air fluid levels are indicative
 Hard to diagnosis radiographically
 Cranial Fractures
 Location of FX is more important that the
extent of the FX
 If FX crosses artery a bleed can occur
causing a hematoma

 Fx that enters mastoid air cells or sinus can

cause an infection that can result in
• Meningitis
• Encephalitis
 Linear Fractures
 Non branching lines that
are intensely radiolucent

 Vascular markings are

occasionally mistaken for
fractures

 Fracture appears more

translucent and
transverses the full
thickness of skull

 Sutures
Linear Skull FX
 Depressed Fracture
 The fractured edges
overlap

 Usually caused by a high

velocity impact with a
small object

 Can cause bleeding into

subarachnoid space

 Best demonstrated with

CR tangential to the FX
Depressed Skull FX
 Basilar Fracture
 Very difficult to demonstrate with x-ray
 Air fluid levels in sphenoid sinuses
 Clouding of mastoid air cells
 Often X-table lateral is done to demonstrate this
 CT & MRI are most often used for this type
 Compression Fracture of spine
 Mostfrequent type of injury involving
vertebral body

 Generally occurs in T and L-spine

 T11- T12 and T12 – L1

 Damage is usually limited to the upper

portion of the vertebral body, particularly to
the anterior margin
Compression FX of Spine
Compression FX of Spine
 Hangman’s Fracture
 FX of the arch of the 2nd c-spine vertebrae

 Usually accompanied by anterior subluxation of the 2nd

and 3rd cervical vertebrae

 Sometimes called traumatic spondylosis

 Resulting from acute hyperextension of the head & neck

 Originally seen commonly in hangings

 Now seen more for MVA
Hangman’s Fracture
Hangman’s Fracture
 Jefferson’s Fracture
 Comminuted FX of the ring of the atlas

 First described as a “burst FX”

 Generally occurs as a result of severe axial force
such as a MVA

 With this FX particular attn needs to be paid to

the transverse longitudinal ligament by reviewing
lateral masses on the open mouth odontoid

 MRI is preferred method for this ligament

Jefferson’s Fracture
Jefferson’s
Fracture
TRAUMATIC DISEASE
 Cerebral Contusion
 Is an injury to the brain tissue caused by a
movement of the brain within the calvaria
after blunt trauma

 Occurs when brain contacts rough skull

surfaces such as orbital floor and petrous
ridges
 CT appearance of
Cerebral Contusion
 CTscans appear as low density areas of
edema and tissue necrosis

 When IV contrast is used it will enhance

several weeks after injury

 Plays an important role in diagnosis

 MR of Cerebral Contusion
 Cerebral edema causes high signal
intensity on T2 scans

 T1 scans may produce high signal regions

 Diagnosis can also include CT, MRI and

PET
 Cerebral
 Treatment:
Contusion  PT is hospitalized
• Prevent shock

 If there is swelling
 Clinical symptoms: medication is given to
decrease cranial
 Drowsiness pressure
 Confusion
 Agitation • Control edema
 Hemiparesis • Drainage of hematoma
 Unequal pupil size
 Surgery is usually not
necessary
Cerebral Contusion
 Hematomas
 Brain trauma often resulting in a hemorrhaging
from a ruptured vein or artery

 Skull does not allow for expansion and pressure

forces brain toward open space (foramen
magnum)

 Can result in major consequences & death if not

treated quickly
 Epidural Hematomas
 Highest mortality relate of the hematomas
 Even when treated quickly mortality rate is 30%

 Results from a torn artery and its branches

 Most often occurs from a FX of the temporal bone
 80% of cases conventional radiograph shows fracture

 Usually meningeal artery with blood pooling

between bones of the skull & dura mater
 Epidural Hematoma

Usually a shift of midline

Toward opposite side
Emergency surgical
CT shows increased decompression is required to
density relieve cranial pressure
 Subdural Hematomas
 Betweenthe dura mater & arachnoid
meningeal layers
 Caused by blunt trauma to frontal or occipital
lobes and can tear subdural veins

 Pushes brain away from skull across

midline (including ventricles)
 Subdural Hematoma

Occurs more slowly On CT appears as a

Because it is a venous curvilinear area of I
Hemorrhage. increased density on
portions or all of the
cerebral hemispheres
 Subdural Hematomas
 Subacute stage (up to several days)
 Appears on CT as a decreased density or
isodense fluid collection

 In chronic state (2-3 weeks)

 The surface of the hematoma becomes
concave
 Delayed coma con occur
 Symptoms of Hematomas
 Headaches

 Agitation

 Drowsiness

 Gradual radiograph deficits

 Treatment of Hematomas
 Insmall hematomas without inclination to
rebleed

 Severe cases

 Less invasive treatment may include

Degenerative Diseases
 Disks act as shock
Herniated Disk
absorbers

 When young nucleus

pulposus contains
large amount of fluid
to cushion spine

 With increased age

the fluid & elasticity
decrease leading to
degenerative disease
and back pain
 Herniated Disk
 May result from either degenerative disease or
trauma

 A weakened or torn annulus is subject to rupture

 Nucleus pulposus protrudes & compresses spinal
nerve roots
 Can prolapse in any direction, sometimes without
pain
 When it projects posteriorly there is pain and
weakening of muscles supplied by those nerves
 Most commonly occurs is lower cervical & lumbar
• Lumbar: Most at L4-L5 and L5 – S1
• Cervical: Most at C6 – C7
• Thoracic: T9-T12
Herniated Disk
 Herniated Disk

 MRI is modality of choice

 CT and Myelography can also be used
 Symptoms of Herniated Disk
 Sudden weak & severe onset of pain

 Compression of nerve roots in C-spine:

 Compression in lumbar in L-spine:

 Treatment: Herniated Disk
 Conservative treatment

 Surgical intervention
Herniated Disk: Fusion
Brain & Spinal
Tumors
 Spinal Tumors
 Primary tumors as less common is spinal
cord than those of the brain
 Divided into extradural and intradural
 Intradural further divided into
• Intramedullary (within spinal cord)
 Most common are: Astrocytoma & Epenymoma

• Extramedullary (outside spinal cord)

 Most common types of primary spinal neoplasm's (>60%)
are: Meningiomas and Neurofibromas
 Symptoms of Spinal Tumors
 Extramedullary  Intramedullary

 Similar symptoms as a  Can cause

herniated nucleus progressive
pulposus paraparesis
 Compress nerve roots  Sensory loss
leading to pain and
muscle weakness
Extramedullary Spinal Tumors

Meningioma
Neurofibroma
Intramedullary Spinal tumors

Astrocytoma Ependymoma
 Imaging of Spinal Tumors
 MRI is the modality of choice

 Conventional radiography
 Can demonstrate bony destruction
 Widening of the vertebral pedicles
 CT myelo may be necessary to identify
extradural tumors
 Treatment of Spinal Tumors
 Both intramedullary and extramedullary
can be removed surgically
 50% of patients who have surgery experience
a reverse of clinical anomalies

 In cases where surgery is contraindicated

 Radiation therapy is the primary means of
treating a tumor
 Brain Tumors
 Gliomas acct for 50% of all brain tumors

 Meningiomas are the most frequently

occurring nonglial tumors

 All tumors have greater incidence in males

 Interfere
with circulation of the CSF
causing a hydrocephalus
 Brain Tumors
 Inchildren 20% of all tumors are brain
tumors
 Most common are astrocytomas,
medulloblastomas, glioblastomas and
craniopharyngliomas
• 30% of primary ped. tumors are medulloblastoma

 In adults most prevalent are:

 Astrocytomas, glioblastomas, metastatic
tumors and menigiomas
 Astrocytomas of Brain

Usually treated
with surgery and
radiation therapy

Have good 5
year survival
rate
 Ependymoma of Brain

Usually treated with surgical removal

Medulloblastomas of Brain
Craniopharyngliomas of Brain
Metastatic Tumor of Brain
 Meningiomas of Brain

Usually benign

More frequent in women

Rare in children

Less common to see

in brain than spinal cord
 Symptoms of Brain Tumors
 Headache
 Nausea and Vomiting
 Lethargy
 Seizures
 Paralysis
 Aphasia
 Blindness
 Deafness
 Abnormal changes in personality & behavior
 Treatment of Brain Tumors
 Surgicalresection
 Radiation therapy

 Survival rate for surgery & Radiation therapy

combined is 80% over a 5 year period
 Rate of survival decrease to 3% over a
10 year period
 Hydrocephalus
 Can be congenital or acquired

 Refers to an excessive amount of fluid in the

ventricles

 Two types
 Non- communicating

 Communicating
 Hydrocephalus
 Non-communicating  Communicating
 Can be congenital
 Can be from tumor
growth
 Trauma (hemorrhage)
 Inflammation
 Can come with
increased cranial
pressure
 Raised intrathoracic
pressure impairing
venous flow
 Inflammation from
meningitis
 Subarachnoid
hemorrhage
 Radiographic Appearance
 Generalized enlargement of the ventricular system

 PA radiograph can reveal separation of the sutures

 CT clearly demonstrates ventricular dilatation

 MRI is more specific in demonstrating the underlying

cause of obstruction or in excluding obstruction

 Ultrasound is useful in utero and in infants

 Sound waves transverse open fontanels
Hydrocephalus
Hydrocephalus
Hydrocephalus Clinical Symptoms
 The cranial size is
enlarged
 Scalp veins distended
 Skin of scalp thin,
fragile and shiny
 Neck muscles
underdeveloped •In adults
 Severe cases •ALOC
 Orbital roofs are
•Ataxia
depressed
•Incontinence
 Eyes displaced

downwards •Decreased intellectual

•capabilities
 Treatment of Hydrocephalus
 Placement of a shunt
 Internal jugular, heart or
peritoneum
 Contains one way valve to
prevent backflow of blood
into ventricles

 Radiographs taken to
verify shunt placement

 CT or MRI done to
evaluate success of
treatment Ventricularjugular Shunt
 Hydrocephalus in Infants
 Affects 1 of every
1000 newborns

 Long maturation of
CNS

 Can be caused by
maternal & fetal
infections, fetal
hypoxia, irradiation,
chemical agents and
mechanical forces
 Hydrocephalus In Utero
 X-ray used to be taken for fetal age and
position
 With hydrocephalic fetus- hard to deliver
vaginally
 Pelvimetry was ordered to determine
measurements of inlet and outlet
 Very uncomfortable
 Three exposures
 Fetal Hydrocephalus
 Communicating  Non-communicating
 The flow of CSF is free
between ventricles &
subarachnoid space
about cauda equina
 Infants head is normal
size but there is
bulging of the frontal
fontanelles
 Caused by poor
absorption of CSF
 Obstruction between
ventricles and cauda
equina
 Most common form of
obstructive
hydrocephalus is from
abnormalities between
the 3rd and 4th
ventricles
 Multiple Sclerosis
 Chronicprogressive disease of the
nervous system
 Affects women more than men at approx 20-
40 years of age

 There is no cure and it s origin is unknown

 Treatment only slows the process
 Some research indicates it may come from
herpes or retrovirus
 Appears more in temperate climants than
tropical climates
 Multiple Sclerosis
 Demyelination of the myelin sheath covering
nervous tissue of spinal cord & white matter
within the brain

 It has episodes of relapses and remission

 Eventually leads to neurological damage

 Impairment of nerve conduction

 Patients life is not shortened

 Quality of life is diminished
Symptoms Of Multiple Sclerosis
 Difficulty speaking  Poor coordination
clearly
 Tremors
 Bladder dysfunction  Muscle weakness

 Muscle impairment  Double vision

 Loss of balance  Nystagmus (rapid eye

movement)
 HALLMARKS OF MS :

SPINAL
BRAIN CORD

DEMYELINATION AREAS
 Imaging of Multiple Sclerosis
 Scars from areas of
demyelinated nerves
 Sclerotic lesions
throughout nervous system
 Called MS plaques

 MRI is modality of choice

 Contrast enhanced can
differentiate active
inflammation from older
brain plaques
 Functional MRI assesses
alterations in normal CSF
function
Multiple Sclerosis: MRI
CT imaging of Multiple Sclerosis
 CT shows old inactive disease
 Well defined areas of decreased attenuation

 With contrast, in an acute phase

 Shows a mixture of decreased density (old)
 Enhancing regions (active)
 Treatment for MS
 Immunosuppressive  Corticosteroids (short
agents term)
 Limit the autoimmune  Shortens the symptomatic
attack periods
 Delays progression of
disease
 Antiviral
 Reduces frequency of
 Slows the progress of the attacks
disease

 Regular exercise
 Beta interferon
 Reduces spasms and
 Immunomodulatory agents increases ROM
that reduce the severity of
the attacks
 Given subcutaneously
 Cerebrovascular Accident (CVA)
 Is an atherosclerotic disease affecting blood
supply to the brain
 3rd leading cause of death in U.S.
 2 types of stroke:
 Ischemic and Hemorrhagic
 Both CT and MRI distinguish between the two
types
 MRI is especially sensitive to infarction within hours of
onset
 CT, at times appears negative for a day or so

 Carotid duplex and MRA are also useful in the

diagnosis of a stroke
 Ischemic Stroke
 Blood clot blocks a blood vessel in the brain
 Is the majority of strokes

 Two types:
 Thrombosis of cerebral artery
• Blood clot that blocks a blood vessel
 Embolism of the brain
• Is a mass of undissolved matter (solid, liquid or gas) present
in a blood vessel brought there by blood current

 Diagnosed with CT and MRI

 Angiography can be used if other modalities are
questionable
 Symptoms of Thrombotic
Ischemic Stroke
 Symptoms come on over hours to days
 Confusion
 Hemiplegia
 Aphasia

 May be preceded by a temporary episode of

nerurologic dysfunction called transient Ischemic
attack (TIA)
 Includes hemiparesis, monocular blindness- clears up
in about 2 hours
Ischemic Stroke: from Embolism
 Sudden onset of symptoms without warning

 Mortality rate is 20%

 Prognosis depends on location, extent, age, and

general health
 Complete recovery is rare
 Deficits remaining after 6 months are likely to be
permanent

 Treatment
 Bed rest
 Clot blockers within 3 hours (recombinant tissue
plasminogen activator (rtPA)
Ischemic Stroke
 Imaging of Ischemic Stroke
 Non-contrast CT scans are most commonly
used

 MRI is also excellent for imaging

 CT, MRA and US may offer info regarding

patency in the brain and carotid arteries

 PET may be used in the future to identify

decreased Oxygen flow and consumption within
the brain
 Hemorrhagic Stroke
 Occurs from a weakening in the diseased blood
vessel
 Typically weakened from atherosclerosis from
hypertension

 Sudden and often lethal because it comes on so

suddenly

 Accounts for 10-15% of all CVA’s

 Two types:
 Subarachnoid and Intracerebral
 Hemorrhagic Stroke
 Most occur in the cerebrum and bleed into
lateral ventricle

 Most often preceded by an intense headache

and vomiting

 LOC follows in minutes and leads to

contralateral hemiplegia or death

 Prognosis is poor
 35% die day after stroke
 15% die within a few weeks, usually from another
vessel rupture
Imaging of Hemorrhagic Strokes
 CT is modality of choice
 Can demonstrate high density blood in the
subarachnoid space in more than 95% of
cases
 Can demonstrate aneurysms greater than
3mm
 With contrast is contraindicated because
surgeon will not operate without an angiogram

 MRIis relatively insensitive for

subarachnoid bleeds
 Treatment of
Hemorrhagic Strokes
 Surgery
 Preceded by a surgical angiogram

 Ifsurgical intervention is postponed so will

the angiogram
Hemorrhagic Stroke
 Pathology Summary and
Modality of Choice
 Pathology Summary: Central Nervous  Glioma
System  MRI, CT
 Pathology Imaging Modalities of  Medulloblastoma
Choice Additive or Subtractive  MRI, CT
Pathology  Meningioma
 Hydrocephalus  CT, MRI
 CT, MRI, sonography in the neonate  Pituitary adenoma
 Meningitis  CT, MRI
 MRI  Craniopharyngioma
 Encephalitis  CT
 MRI  Acoustic neuroma
 Brain abscess  MRI
 CT, MRI  Spinal tumor
 Herniated nucleus pulposus  MRI, radiography, CT, myelography
 MRI, CT, myelography  Both Metastases from other sites
 Cervical spondylosis  MRI, radiography, CTSubtractive
 Radiography Subtractive
 Multiple sclerosis
 MRI
 CVA
 MRI, CT, sonography, PET