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Imaging findings in CNS infections and differential diagnosis
M. Lequin
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OUTLINE
Introduction and terminologyDiagnosis & Differential diagnosisPediatric brain infections
viral infectionsMeningitisEncephalitis acute/chronic
bacterial infectionsMeningitis/cerebritis-abscess/empyema/TB/Lyme
fungal infectionsparasitic infections
Conclusion
Neuroimaging of Pediatric Intracranial Infection—Part 1:Techniques and Bacterial InfectionsJoshua P. Nickerson, MD, Beat Richner, MD, Ky Santy, MD, Maarten H. Lequin, MD, Andrea Poretti, MD,Christopher G. Filippi, MD, Thierry A.G.M. Huisman, MD
Neuroimaging of Pediatric Intracranial Infection—Part 2: TORCH,Viral, Fungal, and Parasitic InfectionsJoshua P. Nickerson, MD, Beat Richner, MD, Ky Santy, MD, Maarten H. Lequin, MD, Andrea Poretti, MD,Christopher G. Filippi, MD, Thierry A.G.M. Huisman, MD
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INTRODUCTION
Pediatric brain infections are:
1. mostly viral
2. mengitis> encephalitis
CNS is vulnerable to infectious agents due to
3. lack of a true lymphatic system
4. little resistance to infection offered by the subarachnoid space
5. CSF facilitates infection spread the brain and into the ventricles
Early diagnosis is important due to the risk of permanent damage in survivors
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TERMINOLOGYCEREBRITIS
1. Focal inflammation of the brain
2. bacterial infections
MYELITIS
3. Focal inflammation of the spinal cord
ENCEPHALITIS
4. Diffuse inflammation throughout the brain
5. Viral infection
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TERMINOLOGY
MENINGITIS
1. Pachymeningitis: involves the pachymeninges (dura mater), manifests usually as epidural or subdural EMPYEMA
2. Leptomeningitis: involves the leptomeninges (pia mater and arachnoid), manifests as inflammatory exudate of the pial and arachnoid membranes, more frequent than pachymeningitis
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TERMINOLOGY
ABSCESS
1. Suppurative inflammatory process with central liquefactive necrosis, encased by granulation tissue
2. Endstage of an untreated cerebritis
3. Bacterial infection
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DIAGNOSIS
How to diagnose a pediatric brain infection?
1. clinical picture
2. laboratory findings
3. imaging
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CLINICAL PICTURE
Non-specific but often severely ill
neonates
fever, lethargy, stupor, seizures,..
older children
fever, headache, seizures, meningeal signs,..
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LABORATORY FINDINGS
CSF
1. elevated WBC (lymphocytes in viral infection)
2. elevated protein
3. positive PCR (viral: herpes, enterovirus)
Blood
1. increased ESR
2. increased WBC (leucocytosis)
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IMAGING
MR is imaging modality of choice
Protocol:
1. Axial/coronal T2 FSE
2. 3D T1 gradient echo -/+ Gd (FS)
3. 3D FLAIR (>2 years)
4. Axial DWI
5. Optional: SWI, ASL and MRS
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CONGENITAL BRAIN INFECTIONS
ToRCH
1. Toxoplasmosis
2. Rubella
3. Cytomegalovirus
4. Herpes simplex virus type 2
hematogeneous transmission may occur at any time during gestation or occasionally at the time of delivery via maternal-to-fetal transfusion
Congenital HIV
in utero, at the delivery or by breastfeeding
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VIRAL INFECTIONS
Viral meningitis (mostly enterovirus)normal imaging findingsAcute encephalitisHSV and many others: CMV, EBV, VZV (chickenpox), ..Subacute and chronic encephalitisRasmussen encephalitissubacute sclerosing panencephalitisPostinfectious encephalitisADEM
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HERPES ENCEPHALITIS
Most common encephalitis, especially in children
HSV type 1 (>3 months)
Fever, vomiting, headache, behavioral disturbances, lethargy and seizures
Positive PCR in CSF
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HERPES ENCEPHALITIS
MR more sensitive than CT
Hyperintense T2 areas in the temporal lobe, insular cortex, orbital surface of the frontal lobe and cingulate gyrus
Petechial hemorrhages
variable enhancement after 3 days (gyral pattern)
DD in bilateral temporal involvement:limbic encephalopathy, SLE, gliomatosis cerebri, enteroviruses
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VARICELLA ZOSTER ENCEPHALITIS
Chickenpox
Acute cerebellar ataxia often around 10 days onset of the rash
varicella specific IgM in serum or PCR in CSF
MRI:
1. Acute cerebellitis, swelling and T2 hyperintensity
2. Small vessel arteriopathy
3. Basal ganglia infarctions due to vasculitis, often unilateral (after 1-12 months)
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VIRAL INFECTIONS
Viral meningitis (mostly enterovirus)normal imaging findingsAcute encephalitisHSV and many others: CMV, EBV, VZV (chickenpox), ..Subacute and chronic encephalitisRasmussen encephalitissubacute sclerosing panencephalitisPostinfectious encephalitisADEM
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RASMUSSEN ENCEPHALITIS
Progressive diseaseAge peak:6-8 yrsEtiology still unclear (viral?, autoimmune?)severe epilepsy, hemiplegiatypical unilaterallesions in basal gangliacerebral cortical swelling (insular) with progressive atrophy
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SSP ENCEPHALITIS
slow virus infection several years after primary measles infection (before the age of 2 years)
rare due to vaccination
age peak: 7-9 y
Progressive psychoneurological deterioration death within 3 years
Different stages:1. Normal imaging 3-4 months after onset2. Patchy asymmetrical T2 hyperintensities in parietotemporal
areas (first peripheral cortex and WM, later deep WM and CC)
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OUTLINE
Introduction and terminologyDiagnosis & Differential diagnosisPediatric brain infections
viral infectionsMeningitisEncephalitis acute/chronic
bacterial infectionsMeningitis/cerebritis-abscess/empyema/TB/Lyme
fungal infectionsparasitic infections
Conclusion
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BACTERIAL INFECTIONS
Bacterial meningitis
Bacterial cerebritis/brain abscess
Empyema
Tuberculosis
Lyme disease (neuroborreliosis)
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BACTERIAL MENINGITISMost common pediatric infection
More in (premature) neonates than infants
One of the most severe infectious processes
Etiology agents vary with the age of the patient
Neonates: group B streptococcus (45-50%), E coli (15-20%), Staph., Listeria, ..
Children: H.influenzae, Neisseria meningitidis, Strept. pneumoniae, ..
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BACTERIAL MENINGITISDiagnosis using clinical signs and CSF
MR imaging when unclear, non responsive to therapy or when complications occur
Mechanism:
1. Hematogenous spread (choroid plexus)
2. Direct implantation (traumatic, CSF leak, ..)
3. local extension (sinusitis, mastoiditis, otitis,..)
4. Spread along the peripheral nervous system
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BACTERIAL MENINGITIS
Imaging:
Depends on neuropathologic stage
May rapidly change from normal to severe edema, destruction in a few days and to multiple infarcts and atrophy in a few weeks (especially in the newborns due to the vulnerability of the immature brain)
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BACTERIAL MENINGITIS
Stage 1/2: choroid plexitis/ventriculitis
plexus adhesions to ventricular wall
ependymal thickening and enhancement
intraventricular debris
hydrocephalus due to obstruction
periventricular edema
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BACTERIAL MENINGITIS
Stage 3: arachnoiditis
1. purulent exudation in the subarachnoid space covers the cranial base (H. Influenzae) or sometimes the cerebral convexity (pneumococcal meningitis)
2. dural or leptomeningeal enhancement
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BACTERIAL MENINGITIS
Stage 4: vasculitis (perivascular spaces)
1. always present in neonatal bacterial meningitis
2. infarction preferential at the cerebral cortex and subcortical white matter but also basal ganglia and periventricular WM.
3. Cerebral infarct are seen in up to 30% of patients with bacterial meningitis
4. Arteritis or (thrombo)phlebitis
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BACTERIAL MENINGITIS
Stage 5: cerebral edema
1. primarily related to vasculitis (vasogenic edema due to BBB changes) but may be complicated by cytotoxic and interstitial edema
2. brain herniation is rare because distensibility of the neonatal vault
3. initially vasogenic due to vasculitis and increased permeability of blood vessels
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BACTERIAL MENINGITIS
Acute stage complications:
1. parenchymal gliosis, neuronal loss
2. subdural effusions (sterile: toxin-induced increased permeability of capillaries and veins, resolve spontaneously)
3. brain abscess (superimposed infection of ischemic lesions, seen in Citrobacter, Proteus and Staph. Aureus)
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BACTERIAL MENINGITIS
Chronic complications:
1. hydrocephalus (often communicating)
2. multicystic encephalomalacia
3. porencephaly
4. atrophy
May lead to brain death
courtesy to A. Poretti
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BACTERIAL INFECTIONS
Bacterial meningitis
Bacterial cerebritis/brain abscess
Empyema
Tuberculosis
Lyme disease (neuroborreliosis)
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CEREBRITIS
Uncommon
Early stage of focal purulent brain infection
Early cerebritis stage: ill defined area of T2 hyperintensity with patchy enhancement
Late cerebritis stage: evolution to abscess
Surgery contra-indicated
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BRAIN ABSCESSuncommon in children, but often large
2/3 in neonates
Citrobacter, Proteus, Pseudomonas, Serratia, Staph. aureus, Streptococcus, Pneumococcus, Candida, toxoplasmosis,..
must be differentiated with necrotic tumors by DWI and MRS
MRS may show lactate, lipids, acetate and succinate peaks and aminoacid peaks
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EMPYEMARare purulent extracerebral collection
Neurosurgical emergency
Epidural due to frontal sinusitis or mastoiditis (lentiform shape)
Subdural after neurosurgery or trauma (crescent shape)
No vasogenic edema, reduced diffusion
Peripheral enhancement
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BACTERIAL INFECTIONS
Bacterial meningitis
Bacterial cerebritis/brain abscess
Empyema
Tuberculosis
Lyme disease (neuroborreliosis)
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TUBERCULOSIS
Tuberculous meningitis:
1. basal leptomeningitis
thick enhancing exudate obliterates the basal cisterns
often communicating hydrocephalus
infarctions (due to vessel invasion), mostly basal ganglia and thalami
2. most children have also parenchymal lesions
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TUBERCULOSIS
Tuberculomas:
mostly supratentorial
usually smaller than 2 cm
caseating tuberculous granulomas
disseminated tuberculosis
multiple small nodular enhancing lesions with edema
Tuberculous abscess rare
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BACTERIAL INFECTIONS
Bacterial meningitis
Bacterial cerebritis/brain abscess
Empyema
Tuberculosis
Lyme disease (neuroborreliosis)
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LYME DISEASE
Borrelia (Burgdorferi)
Neuroborreliosis = rare manifestation of late Lyme disease
General symptoms: erythema migrans, flu-like symptoms
Neuroborreliosis symptoms: headache, sleeping disorders, papiledema, cranial nerve abnormalities
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LYME DISEASE
MR imaging:
1. often negative
2. prominent Virchow-Robin spaces
3. hyperintens WM lesions (MS-like)
4. meningeal and cranial nerve enhancement
Milder course in children than in adults
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OUTLINE
Introduction and terminologyDiagnosis & Differential diagnosisPediatric brain infections
viral infectionsMeningitisEncephalitis acute/chronic
bacterial infectionsMeningitis/cerebritis-abscess/empyema/TB/Lyme
fungal infectionsparasitic infections
Conclusion
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FUNGAL INFECTIONS
uncommon in children
more in immunosuppressed patients
meningitis> meningoencephalitis, abscess
Cryptococcus: meningitis> granuloma
Candida: meningitis, multiple micro-abscesses
Aspergillus: often hemorrhagic abscesses (hypo on T2), ring enhancement
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PARASITIC INFECTIONS
Neurocysticercosis
Echinococcosis
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SARCOIDOSIS
Systemic granulomatous disorder
Unknown origin
CNS involvement 5-10%
Uncommon in children
Facial nerve involvement (>N II and VIII)
Granulomatous leptomeningitis
Diagnosis by exclusion
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CONCLUSIONClinical picture and laboratory findings are more important than imaging
Differentiating infection from other pathology
Imaging findings:1. depend on the age group2. depend on the pathogen3. often non-conclusive
MR protocol should include:T1 with contrast (and FS)DWI
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