abrams intracranial emergenciescme.baptisthealth.net/.../weds_abrams_900_part_1.pdf ·...
TRANSCRIPT
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Non-Traumatic Intracranial Emergencies
Non-Traumatic Intracranial Emergencies
Kevin Abrams, M.D.Chief of Radiology
Medical Director of Neuroradiology & MRIBaptist Hospital, Miami, FL
Themes
Diffuse Lesion: Infection vs Infarction Focal Lesion: Infection vs Tumor
Disclosures
I disclose that I serve as a consultant to Keystone Heart. My presentation will not include discussion of off-label or unapproved usage.
Diffuse: Infection vs Infarction
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NCCT
Basic Vascular Distributions
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PCA Infarct
Basic Vascular Distributions
PCA
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PCA
MCA
Ant Ch Art or MCA
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MCA Infarct Basic Vascular Distributions
Anterior Choroidal Art. Infarct
Next branch above pcom Besides choroid plexus supply,
important supply to uncus and post limb int. capsule
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Case 3
PCA Ant Ch Art
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64 yo male with crohns and dipolpia
4/19
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Several days before…
Invasive Fungal sinusitis aspergillosis
Invasive Fungal sinusitis aspergillosis
Case 4
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Herpes Encephalitis (Type I) A necrotizing encephalitis which is both
viral and indirect immune mediated that has a predilection for the medial temporal lobes, inferior frontal lobes, limbic system
Bimodal age dist. <20 (usu. primary 1/3) and >50(usu. latent reactivation 2/3) thru olfactory bulbs or trigeminal ganglia
Mortality: 70% if untreated; 19% if treated
Morbidity: 50% survivors have moderate to severe deficits
Early initiation of Rx (Acyclovir) is key for Px
Herpes Encephalitis (Type I) Symptoms: fever 90%, ha 80%, psy 70%,
sz 67%, focal weakness 33%, memory 24%
Imaging: swelling med. temp lobes, frontal bases, limbic system, insula. Cingulate gyrus; freq bilat, inc FLAIR, inc T2 DWI restricted, may be hemorrhagic, +/- enhancement
CSF: mono pleo, rbc’s, inc pro., PCR 96% sens., 98 % spec.
EEG: focal spike &slow or periodic sharp waves over temporal lobes.
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Insula + Medial Temporal Lobe= Herpes Encephalitis tpo
Insula + Medial Temporal Lobe= Herpes Encephalitis tpo
Herpes 2nd Case
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Herpes 3rd Case
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NCCT CECT
Case 5
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Limbic Encephalitis
First described in the 1960’s Autoimmune: Ab’s against 1. intracellular antigens:Hu (SLSC),
Ma2(testis nsclc), CV2/CRMP5(sclc, thymoma), amphiphysin, (breast, sclc) 2. cell mb anitgens: VGKC and NMDAR
(thymoma, ov dermoid)
Limbic encephalitis and variants, Tuzun etal, The Neurologist, vol 13 no.5, Sept 2007
Limbic Encephalitis Diag Crit. Paraneoplastic limbic
encephalitis: Path demonstration, OR All 4 of the following:
1.Short trm mem loss, sz, psy sx’s sugg limbic sys 2.<4 yr from onset of neuro sx’s and cancer dx 3.exclusion mets, infn, metabolic, stroke, side effects
of therapy 4. at least one of the following:
CSF with inflamm findings MRI flair or T2 uni or bilat temp lobe hyper EEG with epileptic or slow activity focally involving
temp lobes
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Case 6
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MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Initially described in 1984 Most commonly caused be A to G transition
mutation at position 3243 of the mitochondrial genome (inherited matrinlieally- mom only!)
Impairment of OXPHOS (multi-step process to generate ATP); shunt from pyruvate to lactate -> lactic acidosis
Clinical Syndrome: 1. stroke like syndrome before age 40; 2. encephalopathy sz’s &/or dementia; 3. lactic acidosis (serum or csf) &/or ragged red fibers
Stroke-like sx’s: episodes of partially reversible aphasia, hemianopsia, cortical blindness and eventual dementia
MELAS (Mitochondrial Encephalopathy with Lactic Acidosis and Stroke-Like Symptoms) Imaging: temporal, parietal and occipital lobes
not respecting vasc territories. Mostly cortical but may involve adj. wm.; DWI bright but usu not restricted but can be. Lesions may fluctuate and go from side to side with eventual cortical atrophy. MRS: markedly elevated lactate. CT: B.G. Ca++
Other organ systems: muscles-exercise intolerance, cardiac- conduction (WPW) cardiomyopathy (concentric hypertrophy), endocrine- DM II, short stature, GI
Tx: no effective rx, ?CoQ10 other cocktails
MELAS, Sproule & Kaufmann, Ann NY Acad Sci 1142, 133-158 2008
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Case 7
Dka seizure disorderDka seizure disorder
Csf clean but strep in blood