non-traumatic neuro emergencies
TRANSCRIPT
![Page 1: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/1.jpg)
Department of Radiology University of California
San Diego
John R. Hesselink, M.D.
Non-Traumatic Neuro Emergencies
![Page 2: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/2.jpg)
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
![Page 3: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/3.jpg)
“Acute Focal Neurological Deficit”
![Page 4: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/4.jpg)
Acute Focal Neurological Deficit
Arterial thrombosis, occlusion, dissection or embolus
Brain hemorrhage
Hypotension / Hypoxia
Venous / sinus occlusion
Cortical mass lesion
![Page 5: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/5.jpg)
Neuroradiological Workup
MR imaging T2WI & FLAIR GRE Diffusion T1WI with gadolinium
MRA /MRV
Angiography Diagnosis Thrombolysis Angioplasty
![Page 6: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/6.jpg)
History: 47 y/o man with von-Hippel-Lindau disease & new left arm weakness
486 - 1959187
![Page 7: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/7.jpg)
Dx: Infarct & MCA stenosis
{Page 2}
DWI
ADC
![Page 8: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/8.jpg)
History: 32 y/o woman with headache, confusion & right sided weakness
355 - 1554979
Case 1
![Page 9: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/9.jpg)
{Page 2}
Question?
![Page 10: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/10.jpg)
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
![Page 11: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/11.jpg)
Dx: Thrombosis of superior sagittal sinus, left transverse sinus & deep venous system
Confusion & weakness {Page 3}
![Page 12: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/12.jpg)
Venous / Sinus Occlusion
Hypercoagulable state Pregnancy Sepsis Dehydration Paranasal sinus or mastoid infection Neoplastic invasion
Causes
![Page 13: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/13.jpg)
History: 59 y/o woman with headache and left-sided weakness
187 - 1406140
Case 2
![Page 14: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/14.jpg)
Weakness {Page 2}
T1 - FATSAT
1
2
3 T2W
![Page 15: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/15.jpg)
Dx: Right ICA dissection
{Page 3}
![Page 16: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/16.jpg)
History: 43 y/o man with sudden onset of right face & arm weakness
645 - 0911397
Case 4
![Page 17: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/17.jpg)
{Page 2}
![Page 18: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/18.jpg)
Dx: Hyperacute hemorrhage & AVM
{Page 3}
Question?
![Page 19: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/19.jpg)
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
![Page 20: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/20.jpg)
Intracranial Hemorrhage Non-traumatic
Hypertension
Aneurysm
AV Malformation
Other
Other causes: bleeding into tumor, hypocoagulable state, hemorrhagic infarction and iatrogenic
36%
11%
17%
36%
![Page 21: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/21.jpg)
History: 5 y/o girl with seizures
361 - 1835966
Case 10
![Page 22: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/22.jpg)
{Page 2}
Diffusion image
Question?
![Page 23: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/23.jpg)
How does the DWI image help in differential diagnosis?
1. Indicates hemorrhage
2. Excludes a bacterial abscess
3. Excludes toxoplasmosis
4. Favors a tumor
![Page 24: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/24.jpg)
Dx: Amoebic abscesses
{Page 3}
![Page 25: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/25.jpg)
Pyogenic Brain Abscess
Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece
Acetate
Alanine
Lactate
Cytosolic Acid
![Page 26: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/26.jpg)
“Worst Headache of Life!!”
![Page 27: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/27.jpg)
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
![Page 28: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/28.jpg)
History: 63 y/o man collapsed while preaching on Sunday
369
![Page 29: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/29.jpg)
Dx: p-comm aneurysm
{Page 2}
![Page 30: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/30.jpg)
History: 45 y/o female with severe headache
282 - 1748789
Case 9
![Page 31: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/31.jpg)
{Page 2}
![Page 32: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/32.jpg)
Dx: SAH due to bilobed basilar tip aneurysm
Headache {Page 3}
![Page 33: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/33.jpg)
History: 54 y.o. man with severe
headache
132 - 1600382
![Page 34: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/34.jpg)
Dx: Cocci meningitis
{Page 2}
![Page 35: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/35.jpg)
“Acute / Increasing
Confusion and Obtundation”
![Page 36: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/36.jpg)
Acute / Increasing Confusion & Obtundation
Obstructive hydrocephalus
Brain stem or basal ganglia hemorrhage
Brain herniation
Encephalitis
Meningitis
Metabolic & toxic disorders
Imaging: CT and MRI
![Page 37: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/37.jpg)
246 - 1736874
History: 34 y/o man with intermittent chronic headaches & acute decreased mental status
Case 7
![Page 38: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/38.jpg)
Headaches {Page 2}
![Page 39: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/39.jpg)
Dx: Colloid cyst
{Page 3}
![Page 40: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/40.jpg)
Cerebellar Astrocytoma
G 53-55
![Page 41: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/41.jpg)
History: 50 y/o female with acute onset of headache & confusion
540 - 2054429
Case 5
![Page 42: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/42.jpg)
Dx: Herpes simplex encephalitis
{Page 2}
![Page 43: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/43.jpg)
Herpes Simplex Encephalitis
Rapid course
Temporal lobes, inferior frontal & insular cortex
Cortical edema & mass effect
Gyral enhancement
Early therapy critical
![Page 44: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/44.jpg)
Meningitis
Organisms Bacteria Virus (meningoencephalitis) Tuberculosis Fungus
Enhancement of basal cisterns Differential diagnosis
Leptomeningeal seeding of tumor Encephalitis
![Page 45: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/45.jpg)
History: 39 woman with SLE on chronic immunosuppression
with steroids & methotrexate
701 – 1480813
![Page 46: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/46.jpg)
{Page 2}
Dx: TB meningitis
![Page 47: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/47.jpg)
498 - 2007173
Newborn with low APGAR scores
T1W
T2W
![Page 48: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/48.jpg)
1
2
{Page 2} 1
2
DWI
![Page 49: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/49.jpg)
History: 30 y.o. diabetic female was brought to the ED in a coma
108 - 1669246
![Page 50: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/50.jpg)
Coma {Page 2} 2 days later
Dx: Hypoglycemia – Insulin overdose
![Page 51: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/51.jpg)
“Acute / Progressive
Visual Deficit”
![Page 52: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/52.jpg)
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
![Page 53: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/53.jpg)
Neuroradiological Workup
Orbital ultrasound
Globe & anterior compartment
CT for orbit
MRI is best overall
![Page 54: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/54.jpg)
145 - 0681151
History: 44 y.o. man with eye swelling, ophthalmoplegia & acute visual loss
Case 6
Question?
![Page 55: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/55.jpg)
Which compartments of the orbit are involved by the disease?
1. Intraconal space
2. Extraconal space
3. Preceptal space
4. All of the above
![Page 56: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/56.jpg)
Dx: Orbital cellulitis with SOF extension
{Page 2}
![Page 57: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/57.jpg)
Dx: Devic’s disease
History: 27 y/o woman with loss of vision in left eye
![Page 58: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/58.jpg)
History: 37 y/o man with headaches & decreased vision
541 - 2054553
Case 11
![Page 59: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/59.jpg)
{Page 2}
![Page 60: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/60.jpg)
Dx: Hemorrhagic Pituitary adenoma
{Page 3}
![Page 61: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/61.jpg)
History: 49 y/o man with a visual deficits & lightheadedness
377 - p8145
![Page 62: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/62.jpg)
Dx: Hippocampal infarct
{Page 2}
![Page 63: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/63.jpg)
“Acute / Progressive
Myelopathy”
![Page 64: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/64.jpg)
Acute / Progressive Myelopathy
Epidural hemorrhage Epidural abscess Tumor Inflammatory diseases Ischemia Cervical or thoracic disk extrusion Imaging: MRI
![Page 65: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/65.jpg)
History: 40 y/o male with fever, back pain, and a T6 sensory level
423 - 0920959
Case 3
![Page 66: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/66.jpg)
Dx: Epidural abscess
{Page 2}
![Page 67: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/67.jpg)
517 - 1844769
History: 35 y/o man with back pain & leg weakness
Case 8
![Page 68: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/68.jpg)
Dx: Staph osteomyelitis
{Page 2}
![Page 69: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/69.jpg)
History: 65 y/o woman with back pain & progressive leg weakness & gait problem for 2 months
656 - 2166583
![Page 70: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/70.jpg)
Dx: Plasmacytoma
{Page 2}
![Page 71: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/71.jpg)
Dx: Epidural lymphoma
History: 32 y/o man with back pain
557
![Page 72: Non-Traumatic Neuro Emergencies](https://reader031.vdocuments.net/reader031/viewer/2022012102/616a009211a7b741a34dbc9a/html5/thumbnails/72.jpg)
UCSD Neuroradiology Teaching File Website
URL - http://spinwarp.ucsd.edu/NeuroWeb/