CNS Pathology RT 91 Spring 2012 1. INFLAMMATORY DISEASE OF CNS 2

CNS PathologyCNS Pathology

RT 91 RT 91

Spring 2012Spring 2012

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INFLAMMATORY INFLAMMATORY DISEASE OF CNSDISEASE OF CNS

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MeningitisMeningitis Inflammation fo the meningeal coverings of the brain and Inflammation fo the meningeal coverings of the brain and

spinal cordspinal cord

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

Bacterial is most common (can cause hydrocephalus)Bacterial is most common (can cause hydrocephalus) Three types pus forming bacteria:Three types pus forming bacteria:

Meningococci - infantsMeningococci - infants Streptococci - childrenStreptococci - children Pneumococci- adultsPneumococci- adults

Tubercle bacillusTubercle bacillus

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Different Pathogens causing Different Pathogens causing MeningitisMeningitis

FungiFungi Chronic meningitisChronic meningitis Often associated with AIDS and immunodepressant Often associated with AIDS and immunodepressant

drug therapydrug therapy VirusVirus

Viral meningitis can be caused by mumps, poliovirus Viral meningitis can be caused by mumps, poliovirus and herpes simplexand herpes simplex

BacteriaBacteria Most commonMost common Bacteria release toxins that destroy meningeal cells Bacteria release toxins that destroy meningeal cells

stimulating immune & inflammatory reactionsstimulating immune & inflammatory reactions

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Acute Meningitis Acute Meningitis Clinical SymptomsClinical Symptoms

FeverFever HeadacheHeadache Stiff neckStiff neck VomitingVomiting Changes in LOCChanges in LOC Severely ill in 24 hoursSeverely ill in 24 hours RashRash Chronic symptoms are Chronic symptoms are

the same but occur over the same but occur over weeksweeks

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Diagnosis of MeningitisDiagnosis of Meningitis Brain CTBrain CT

Rule out contraindications to do a spinal tapRule out contraindications to do a spinal tap

Spinal tapSpinal tap LP to remove CSF to send to labLP to remove CSF to send to lab

Sometimes MRI is used Sometimes MRI is used

Is most sensitive modality for demonstrating pia and Is most sensitive modality for demonstrating pia and arachnoid arachnoid

Treatment includes antibiotics and if secondary Treatment includes antibiotics and if secondary to encephalitis: antiviral drugsto encephalitis: antiviral drugs

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Radiographic AppearanceRadiographic Appearance

Initially meninges Initially meninges show vascular show vascular congestion, edema congestion, edema and minute and minute hemorrhageshemorrhages

MRI and CT scans MRI and CT scans could appear normal could appear normal if appropriate therapy if appropriate therapy is done right awayis done right away Meningitis as a result of a Staph infection

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EncephalitisEncephalitis

Infection of the brain tissue that is viralInfection of the brain tissue that is viral May occur subsequent to chickenpox, small May occur subsequent to chickenpox, small

pox, influenza and measlespox, influenza and measles May be caused by mosquitoes and herpesMay be caused by mosquitoes and herpes

Survival rates depend of cause of the Survival rates depend of cause of the disease (can be fatal)disease (can be fatal) 30% of cases in children30% of cases in children When caused by herpes it is often fatalWhen caused by herpes it is often fatal

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EncephalitisEncephalitis

MRI is modality of MRI is modality of choicechoice

Results in cerebral Results in cerebral edema and edema and hemorrhagic lesionshemorrhagic lesions

More serious than More serious than meningitis because it meningitis because it frequently develops frequently develops permanent neurologic permanent neurologic disabilitiesdisabilities

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Encephalitis:Encephalitis:Symptoms and TreatmentSymptoms and Treatment

Symptoms:Symptoms: HeadacheHeadache

MalaiseMalaise

ComaComa

FeverFever

SeizuresSeizures

Treatment:Treatment: Treated with antiviral Treated with antiviral

medicationsmedications

Herpes induced is Herpes induced is treated with Acyclovirtreated with Acyclovir

• Interferes with DNA Interferes with DNA synthesis and inhibits synthesis and inhibits viral replicationviral replication

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CONGENITAL CONGENITAL DISEASES OF CNSDISEASES OF CNS

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Spinal BifidaSpinal Bifida Is a congenital diseaseIs a congenital disease

Bony neural arch that not completely closedBony neural arch that not completely closed

Most common in lumbar regionMost common in lumbar region May or may not herniate through openingMay or may not herniate through opening

Can range in risk from treatable to life threateningCan range in risk from treatable to life threatening

Can be diagnosed in utero Can be diagnosed in utero With amniocentesisWith amniocentesis UltrasoundUltrasound Elevated beta fetoprotein in mother’s bloodElevated beta fetoprotein in mother’s blood

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Types of Spinal BifidaTypes of Spinal Bifida

MeningoceleMeningocele Only the meninges protrudeOnly the meninges protrude Local defect of bone & duraLocal defect of bone & dura

MyeloceleMyelocele Protrusion of spinal cordProtrusion of spinal cord

MeningomyeloceleMeningomyelocele Protrusion of meninges and Protrusion of meninges and

spinal cord into the skin of the spinal cord into the skin of the backback

Most seriousMost serious

Spinal bifida occultaSpinal bifida occulta No protrusion of spinal No protrusion of spinal

contentscontents Least severeLeast severe 1313


Can be demonstrated Can be demonstrated with CT, MRI and with CT, MRI and myelographymyelography Prenatally with Prenatally with

ultrasound (in utero)ultrasound (in utero)

Large bony defectsLarge bony defects

Herniated spinal Herniated spinal contentscontents

Meningomyelocele

Meningocele

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MeningomyeloceleMeningomyelocele

Most serious Most serious Affected PT’s have Affected PT’s have

severe neurologic severe neurologic deficitsdeficits ParaplegiaParaplegia Diminished control of Diminished control of

lower limbs, bladder lower limbs, bladder and bowelsand bowels

Hydrocephalus is Hydrocephalus is commoncommon

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Spinal Bifida ImagingSpinal Bifida Imaging

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Spinal Bifida TreatmentSpinal Bifida Treatment

Can be surgically repairedCan be surgically repaired Neurological damage is permanent still and cannot be Neurological damage is permanent still and cannot be

reversedreversed

Most measures are supportive rather than Most measures are supportive rather than correctivecorrective Physical therapyPhysical therapy Physical supportsPhysical supports BracesBraces SplintsSplints

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CRANIAL AND SPINAL CRANIAL AND SPINAL FRACTURESFRACTURES

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Cranial FracturesCranial Fractures Cerebral fractures usually occurs to Cerebral fractures usually occurs to

fractures of the calvaria of the skullfractures of the calvaria of the skull 3 types of cranial fractures3 types of cranial fractures

Linear- straight and sharply definedLinear- straight and sharply defined• Is 80% of all cranial fracturesIs 80% of all cranial fractures

Depressed- curvilinear densityDepressed- curvilinear density

Basilar- Air fluid levels are indicative Basilar- Air fluid levels are indicative • Hard to diagnosis radiographicallyHard to diagnosis radiographically

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Cranial FracturesCranial Fractures

Location of FX is more important that the Location of FX is more important that the extent of the FXextent of the FX If FX crosses artery a bleed can occur If FX crosses artery a bleed can occur

causing a hematomacausing a hematoma

Fx that enters mastoid air cells or sinus can Fx that enters mastoid air cells or sinus can cause an infection that can result incause an infection that can result in• Meningitis Meningitis • EncephalitisEncephalitis

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Linear FracturesLinear Fractures Non branching lines that Non branching lines that

are intensely radiolucentare intensely radiolucent

Vascular markings are Vascular markings are occasionally mistaken for occasionally mistaken for fracturesfractures

Fracture appears more Fracture appears more translucent and translucent and transverses the full transverses the full thickness of skullthickness of skull

SuturesSutures

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Linear Skull FXLinear Skull FX

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Depressed FractureDepressed Fracture The fractured edges The fractured edges

overlapoverlap

Usually caused by a high Usually caused by a high velocity impact with a velocity impact with a small objectsmall object

Can cause bleeding into Can cause bleeding into subarachnoid spacesubarachnoid space

Best demonstrated with Best demonstrated with CR tangential to the FXCR tangential to the FX

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Depressed Skull FXDepressed Skull FX

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Basilar FractureBasilar Fracture Very difficult to demonstrate with x-rayVery difficult to demonstrate with x-ray

Air fluid levels in sphenoid sinusesAir fluid levels in sphenoid sinuses Clouding of mastoid air cellsClouding of mastoid air cells

Often X-table lateral is done to demonstrate thisOften X-table lateral is done to demonstrate this CT & MRI are most often used for this type CT & MRI are most often used for this type

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Compression Fracture of spineCompression Fracture of spine

Most frequent type of injury involving Most frequent type of injury involving vertebral bodyvertebral body

Generally occurs in T and L-spineGenerally occurs in T and L-spine T11- T12 and T12 – L1T11- T12 and T12 – L1

Damage is usually limited to the upper Damage is usually limited to the upper portion of the vertebral body, particularly to portion of the vertebral body, particularly to the anterior marginthe anterior margin

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Compression FX of SpineCompression FX of Spine

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Compression FX of SpineCompression FX of Spine

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Hangman’s FractureHangman’s Fracture

FX of the arch of the 2FX of the arch of the 2ndnd c-spine vertebrae c-spine vertebrae Usually accompanied by anterior Usually accompanied by anterior

subluxation of the 2subluxation of the 2ndnd and 3 and 3rdrd cervical cervical vertebraevertebrae

Sometimes called traumatic spondylosisSometimes called traumatic spondylosis Resulting from acute hyperextension of Resulting from acute hyperextension of

the head & neckthe head & neck Originally seen commonly in hangingsOriginally seen commonly in hangings

Now seen more for MVANow seen more for MVA

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Jefferson’s FractureJefferson’s Fracture

Comminuted FX of the ring of the atlasComminuted FX of the ring of the atlas First described as a “burst FX” First described as a “burst FX”

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

With this FX particular attn needs to be With this FX particular attn needs to be paid to the transverse longitudinal paid to the transverse longitudinal ligament by reviewing lateral masses on ligament by reviewing lateral masses on the open mouth odontoidthe open mouth odontoid

MRI is preferred method for this ligamentMRI is preferred method for this ligament

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Jefferson’s FractureJefferson’s Fracture

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Jefferson’s Jefferson’s Fracture Fracture

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TRAUMATIC DISEASETRAUMATIC DISEASE

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Cerebral ContusionCerebral Contusion Is an injury to the brain tissue caused by a Is an injury to the brain tissue caused by a

movement of the brain within the calvaria movement of the brain within the calvaria after blunt traumaafter blunt trauma

Occurs when brain contacts rough skull Occurs when brain contacts rough skull surfaces such as orbital floor and petrous surfaces such as orbital floor and petrous ridgesridges PT usually loses consciousness and cannot PT usually loses consciousness and cannot

remember traumatic eventremember traumatic event Persitent LOC over 24 hrs is a coma and can Persitent LOC over 24 hrs is a coma and can

be fatalbe fatal3636

CT appearance of CT appearance of Cerebral ContusionCerebral Contusion

CT scans appear as low density areas of edema CT scans appear as low density areas of edema and tissue necrosisand tissue necrosis With or without homogenous density zones reflecting With or without homogenous density zones reflecting

areas of hemorragheareas of hemorraghe Most common sites of injury are frontal and anterior Most common sites of injury are frontal and anterior

temporal regions.temporal regions.

When IV contrast is used it will enhance several When IV contrast is used it will enhance several weeks after injuryweeks after injury

Plays an important role in diagnosisPlays an important role in diagnosis

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MR of Cerebral ContusionMR of Cerebral Contusion

Cerebral edema causes high signal Cerebral edema causes high signal intensity on T2 scansintensity on T2 scans

T1 scans may produce high signal regionsT1 scans may produce high signal regions

Diagnosis can also include CT, MRI and Diagnosis can also include CT, MRI and PETPET

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Cerebral Cerebral ContusionContusion

Clinical symptoms:Clinical symptoms: DrowsinessDrowsiness ConfusionConfusion AgitiationAgitiation HemiparesisHemiparesis Unequal pupil sizeUnequal pupil size

Treatment:Treatment: PT is hospitalizedPT is hospitalized

• Prevent shockPrevent shock

If there is swelling If there is swelling medication is given to medication is given to decrease cranial decrease cranial pressurepressure

• Control edemaControl edema• Drainage of hematomaDrainage of hematoma

Surgery is usually not Surgery is usually not necessarynecessary

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Cerebral ContusionCerebral Contusion

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HematomasHematomas Brain trauma often resulting in a hemorrhaging Brain trauma often resulting in a hemorrhaging

from a ruptured vein or arteryfrom a ruptured vein or artery Venous bleeding occurs more slowly than arterial Venous bleeding occurs more slowly than arterial

bleedingbleeding Arterial bleed accumulates fast & causes neurologic Arterial bleed accumulates fast & causes neurologic

symptoms & comasymptoms & coma Both can cause edema in the brain and cause an Both can cause edema in the brain and cause an

increase in intracranial pressureincrease in intracranial pressure

Skull does not allow for expansion and pressure Skull does not allow for expansion and pressure forces brain toward open space (foramen forces brain toward open space (foramen magnum)magnum)

Can result in major consequences & death if not Can result in major consequences & death if not treated quicklytreated quickly

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Epidural HematomasEpidural Hematomas

Highest mortality rate of the hematomasHighest mortality rate of the hematomas Even when treated quickly mortality rate is 30%Even when treated quickly mortality rate is 30%

Results from a torn artery and its branchesResults from a torn artery and its branches Most often occurs from a FX of the temporal boneMost often occurs from a FX of the temporal bone 80% of cases conventional radiograph shows fracture80% of cases conventional radiograph shows fracture

Usually meningeal artery with blood pooling Usually meningeal artery with blood pooling between bones of the skull & dura materbetween bones of the skull & dura mater

http://www.youtube.com/watch?v=cVUofakFIyw&feature=related

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Epidural HematomaEpidural Hematoma

Usually a shift of midlineToward opposite side

CT shows increased density

Emergency surgicaldecompression is required to relieve cranial pressure 4343

Subdural HematomasSubdural Hematomas

Between the dura mater & arachnoid Between the dura mater & arachnoid meningeal layersmeningeal layers Caused by blunt trauma to frontal or occipital Caused by blunt trauma to frontal or occipital

lobes and can tear subdural veinslobes and can tear subdural veins

Pushes brain away from skull across Pushes brain away from skull across midline (including ventricles)midline (including ventricles)

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http://www.youtube.com/watch?v=qO16QXMxBLY&feature=related

Subdural HematomaSubdural Hematoma

Occurs more slowlyBecause it is a venousHemorrhage.

On CT appears as a curvilinear area of Iincreased density on portions or all of the cerebral hemispheres4545

Subdural HematomasSubdural Hematomas

Subacute stage (up to several days)Subacute stage (up to several days) Appears on CT as a decreased density or Appears on CT as a decreased density or

isodense fluid collectionisodense fluid collection

In chronic state (2-3 weeks)In chronic state (2-3 weeks) The surface of the hematoma becomes The surface of the hematoma becomes

concaveconcave Delayed coma con occurDelayed coma con occur

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Symptoms of HematomasSymptoms of Hematomas

HeadachesHeadaches

AgitationAgitation

DrowsinessDrowsiness

Gradual radiograph deficitsGradual radiograph deficits

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Treatment of HematomasTreatment of Hematomas In small hematomas without inclination to In small hematomas without inclination to

rebleedrebleed the hemorrhage is reabsorbed naturally the hemorrhage is reabsorbed naturally no treatment is necessaryno treatment is necessary

Severe casesSevere cases Require surgical ligationRequire surgical ligation Evacuation of hematoma to prevent herniationEvacuation of hematoma to prevent herniation

Less invasive treatment may includeLess invasive treatment may include Drug therapyDrug therapy Intraventricular catheter to remove CSF, which may Intraventricular catheter to remove CSF, which may

cause herniationcause herniation 4848

Degenerative DiseasesDegenerative Diseases

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Herniated DiskHerniated Disk Disks act as shock Disks act as shock absorbersabsorbers

When young nucleus When young nucleus pulposus contains pulposus contains large amount of fluid large amount of fluid to cushion spineto cushion spine

With increased age With increased age the fluid & elasticity the fluid & elasticity decrease leading to decrease leading to degenerative disease degenerative disease and back painand back pain

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Herniated DiskHerniated Disk May result from either degenerative disease or May result from either degenerative disease or

traumatrauma

A weakened or torn annulus is subject to ruptureA weakened or torn annulus is subject to rupture Nucleus pulposus protrudes & compresses spinal Nucleus pulposus protrudes & compresses spinal

nerve rootsnerve roots Can prolapse in any direction, sometimes without painCan prolapse in any direction, sometimes without pain When it projects posteriorly there is pain and When it projects posteriorly there is pain and

weakening of muscles supplied by those nervesweakening of muscles supplied by those nerves Most commonly occurs is lower cervical & lumbarMost commonly occurs is lower cervical & lumbar

• Lumbar: Most at L4-L5 and L5 – S1Lumbar: Most at L4-L5 and L5 – S1• Cervical: Most at C6 – C7Cervical: Most at C6 – C7• Thoracic: T9-T12Thoracic: T9-T12

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Herniated DiskHerniated Disk

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Herniated DiskHerniated Disk

MRI is modality of choiceMRI is modality of choice CT and Myelography can also be usedCT and Myelography can also be used

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Symptoms of Herniated DiskSymptoms of Herniated Disk

Sudden weak & severe onset of painSudden weak & severe onset of pain Weakened musclesWeakened muscles

Compression of nerve roots in C-spine:Compression of nerve roots in C-spine: Cause pain and weakness in neck & upper Cause pain and weakness in neck & upper

extremitiesextremities Compression in lumbar in L-spine:Compression in lumbar in L-spine:

Causes pain in hip, posterior thigh, calf and Causes pain in hip, posterior thigh, calf and foot (sciatica)foot (sciatica)

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Treatment: Herniated DiskTreatment: Herniated Disk

Conservative treatment:Conservative treatment: Bed rest, analgesics and muscle relaxantsBed rest, analgesics and muscle relaxants Followed by physical therapyFollowed by physical therapy 95% recover is 3 months without surgery95% recover is 3 months without surgery

Surgical interventionSurgical intervention DiskectomyDiskectomy Surgical decompressionSurgical decompression Spinal fusionSpinal fusion LaminectomyLaminectomy

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Herniated Disk: FusionHerniated Disk: Fusion

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Brain & Spinal Brain & Spinal TumorsTumors

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Spinal TumorsSpinal Tumors

Primary tumors are less common is spinal Primary tumors are less common is spinal cord than those of the braincord than those of the brain

Divided into extradural and intraduralDivided into extradural and intradural Intradural further divided intoIntradural further divided into

• Intramedullary (within spinal cord)Intramedullary (within spinal cord) Most common are: Astrocytoma & EpenymomaMost common are: Astrocytoma & Epenymoma

• Extramedullary (outside spinal cord)Extramedullary (outside spinal cord) Most common types of primary spinal neoplasm's Most common types of primary spinal neoplasm's

(>60%) are: Meningiomas and Neurofibromas(>60%) are: Meningiomas and Neurofibromas

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Symptoms of Spinal TumorsSymptoms of Spinal Tumors

ExtramedullaryExtramedullary

Similar symptoms as a Similar symptoms as a herniated nucleus herniated nucleus pulposuspulposus

Compress nerve roots Compress nerve roots leading to pain and leading to pain and muscle weaknessmuscle weakness

IntramedullaryIntramedullary

Can cause Can cause progressive progressive paraparesisparaparesis

Sensory lossSensory loss

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Extramedullary Spinal TumorsExtramedullary Spinal Tumors

NeurofibromaMeningioma

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Intramedullary Spinal tumorsIntramedullary Spinal tumors

Astrocytoma Ependymoma 6161

Imaging of Spinal TumorsImaging of Spinal Tumors

MRI is the modality of choiceMRI is the modality of choice

Conventional radiographyConventional radiography Can demonstrate bony destructionCan demonstrate bony destruction Widening of the vertebral pediclesWidening of the vertebral pedicles CT myelo may be necessary to identify CT myelo may be necessary to identify

extradural tumorsextradural tumors

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Treatment of Spinal TumorsTreatment of Spinal Tumors

Both intramedullary and extramedullary Both intramedullary and extramedullary can be removed surgicallycan be removed surgically 50% of patients who have surgery experience 50% of patients who have surgery experience

a reverse of clinical anomaliesa reverse of clinical anomalies

In cases where surgery is contraindicatedIn cases where surgery is contraindicated Radiation therapy is the primary means of Radiation therapy is the primary means of

treating a tumortreating a tumor

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Brain TumorsBrain Tumors Gliomas acct for 50% of all brain tumorsGliomas acct for 50% of all brain tumors

Types of gliomas include: Astrocytoma & Types of gliomas include: Astrocytoma & ependymomaependymoma

Ependymomas predominate in 3-4 yr oldsEpendymomas predominate in 3-4 yr olds

Meningiomas are the most frequently occurring Meningiomas are the most frequently occurring nonglial tumorsnonglial tumors Primarily affecting adults around 50 yrs oldPrimarily affecting adults around 50 yrs old They are non-aggressiveThey are non-aggressive

All tumors have greater incidence in malesAll tumors have greater incidence in males

Interfere with circulation of the CSF causing a Interfere with circulation of the CSF causing a hydrocephalushydrocephalus 6464

Brain TumorsBrain Tumors In children 20% of all tumors are brain In children 20% of all tumors are brain

tumorstumors 60 – 70% are located in the cerebellum & 60 – 70% are located in the cerebellum &

posterior fossaposterior fossa Most common are astrocytomas, Most common are astrocytomas,

medulloblastomas, glioblastomas and medulloblastomas, glioblastomas and craniopharyngliomascraniopharyngliomas• 30% of primary ped. Tumors are medulloblastoma30% of primary ped. Tumors are medulloblastoma

In adults most prevalent are:In adults most prevalent are: Astrocytomas, glioblastomas, metastatic Astrocytomas, glioblastomas, metastatic

tumors and menigiomastumors and menigiomas6565

Astrocytomas of BrainAstrocytomas of Brain

Usually treated with surgery and radiation therapy

Have good 5 year survival rate

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Ependymoma of BrainEpendymoma of Brain

Usually treated with surgical removal 6767

Medulloblastomas of BrainMedulloblastomas of Brain

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Craniopharyngliomas of BrainCraniopharyngliomas of Brain

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Metastatic Tumor of BrainMetastatic Tumor of Brain

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Meningiomas of BrainMeningiomas of Brain

Usually benign

More frequent in women

Rare in children

Less common to see in brain than spinal cord

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Symptoms of Brain TumorsSymptoms of Brain Tumors

HeadacheHeadache Nausea and VomitingNausea and Vomiting LethargyLethargy SeizuresSeizures ParalysisParalysis AphasiaAphasia BlindnessBlindness DeafnessDeafness Abnormal changes in personality & behaviorAbnormal changes in personality & behavior

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Treatment of Brain TumorsTreatment of Brain Tumors

Surgical resectionSurgical resection Radiation therapyRadiation therapy

Survival rate for surgery & Radiation therapy Survival rate for surgery & Radiation therapy combined is 80% over a 5 year periodcombined is 80% over a 5 year period

Rate of survival decrease to 3% over a Rate of survival decrease to 3% over a 10 year period10 year period

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HydrocephalusHydrocephalus

Can be congenital or acquiredCan be congenital or acquired Refers to an excessive amount of fluid in the Refers to an excessive amount of fluid in the

ventriclesventricles Two typesTwo types

Non- communicatingNon- communicating• Interferes or blocks normal CSF circulation from the Interferes or blocks normal CSF circulation from the

ventricles to the subarachnoid spaceventricles to the subarachnoid space CommunicatingCommunicating

• Poor absorption of the CSF by the arachnoid VilliPoor absorption of the CSF by the arachnoid Villi Least common cause is from overproduction of CSFLeast common cause is from overproduction of CSF

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Non-communicatingNon-communicating Can be congenitalCan be congenital Can be from tumor Can be from tumor

growthgrowth Trauma (hemorrhage)Trauma (hemorrhage) InflammationInflammation

CommunicatingCommunicating Can come with Can come with

increased cranial increased cranial pressurepressure

Raised intrathoracic Raised intrathoracic pressure impairing pressure impairing venous flowvenous flow

Inflammation from Inflammation from meningitismeningitis

Subarachnoid Subarachnoid hemorrhagehemorrhage

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Generalized enlargement of the ventricular systemGeneralized enlargement of the ventricular system

PA radiograph can reveal separation of the suturesPA radiograph can reveal separation of the sutures

CT clearly demonstrates ventricular dilatation CT clearly demonstrates ventricular dilatation

MRI is more specific in demonstrating the underlying MRI is more specific in demonstrating the underlying cause of obstruction or in excluding obstructioncause of obstruction or in excluding obstruction

Ultrasound is useful in utero and in infantsUltrasound is useful in utero and in infants Sound waves transverse open fontanelsSound waves transverse open fontanels

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Hydrocephalus Clinical SymptomsHydrocephalus Clinical Symptoms

The cranial size is The cranial size is enlargedenlarged

Scalp veins distendedScalp veins distended Skin of scalp thin, Skin of scalp thin,

fragile and shinyfragile and shiny Neck muscles Neck muscles

underdevelopedunderdeveloped Severe casesSevere cases

Orbital roofs are Orbital roofs are depresseddepressed

Eyes displaced Eyes displaced downwardsdownwards

•In adults •ALOC•Ataxia•Incontinence•Decreased intellectual capabilities 7979

Treatment of HydrocephalusTreatment of Hydrocephalus Placement of a shuntPlacement of a shunt

Internal jugular, heart or Internal jugular, heart or peritoneumperitoneum

Contains one way valve to Contains one way valve to prevent backflow of blood prevent backflow of blood into ventriclesinto ventricles

Radiographs taken to Radiographs taken to verify shunt placementverify shunt placement

CT or MRI done to CT or MRI done to evaluate success of evaluate success of treatmenttreatment Ventricularjugular Shunt

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http://www.youtube.com/watch?v=Qmym2iFVNw8

http://www.youtube.com/watch?v=0h7Xa-Lsnac

Hydrocephalus in InfantsHydrocephalus in Infants

Affects 1 of every Affects 1 of every 1000 newborns1000 newborns

Long maturation of Long maturation of CNSCNS

Can be caused by Can be caused by maternal & fetal maternal & fetal infections, fetal infections, fetal hypoxia, irradiation, hypoxia, irradiation, chemical agents and chemical agents and mechanical forcesmechanical forces

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Hydrocephalus In UteroHydrocephalus In Utero

X-ray used to be taken for fetal age and X-ray used to be taken for fetal age and positionposition

With hydrocephalic fetus- hard to deliver With hydrocephalic fetus- hard to deliver vaginallyvaginally

Pelvimetry was ordered to determine Pelvimetry was ordered to determine measurements of inlet and outletmeasurements of inlet and outlet Very uncomfortable Very uncomfortable Three exposuresThree exposures

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Fetal HydrocephalusFetal Hydrocephalus

CommunicatingCommunicating The flow of CSF is free The flow of CSF is free

between ventricles & between ventricles & subarachnoid space subarachnoid space about cauda equinaabout cauda equina

Infants head is normal Infants head is normal size but there is size but there is bulging of the frontal bulging of the frontal fontanellesfontanelles

Caused by poor Caused by poor absorption of CSFabsorption of CSF

Non-communicatingNon-communicating Obstruction between Obstruction between

ventricles and cauda ventricles and cauda equinaequina

Most common form of Most common form of obstructive obstructive hydrocephalus is from hydrocephalus is from abnormalities between abnormalities between the 3the 3rdrd and 4 and 4thth ventriclesventricles

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Multiple SclerosisMultiple Sclerosis

Chronic progressive disease of the Chronic progressive disease of the nervous systemnervous system Affects women more than men at approx 20-Affects women more than men at approx 20-

40 years of age40 years of age

There is no cure and its origin is unknownThere is no cure and its origin is unknown Treatment only slows the processTreatment only slows the process Some research indicates it may come from Some research indicates it may come from

herpes or retrovirusherpes or retrovirus Appears more in temperate climates than Appears more in temperate climates than

tropical climatestropical climates8484

Multiple SclerosisMultiple Sclerosis Demyelination of the myelin sheath covering Demyelination of the myelin sheath covering

nervous tissue of spinal cord & white matter nervous tissue of spinal cord & white matter within the brainwithin the brain

It has episodes of relapses and remissionIt has episodes of relapses and remission

Eventually leads to neurological damageEventually leads to neurological damage Impairment of nerve conductionImpairment of nerve conduction

Patients life is not shortenedPatients life is not shortened Quality of life is diminishedQuality of life is diminished

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Symptoms Of Multiple SclerosisSymptoms Of Multiple Sclerosis

Difficulty speaking Difficulty speaking clearlyclearly

Bladder dysfunctionBladder dysfunction

Muscle impairmentMuscle impairment

Loss of balanceLoss of balance

Poor coordination Poor coordination

TremorsTremors Muscle weakness Muscle weakness

Double visionDouble vision

Nystagmus (rapid eye Nystagmus (rapid eye movement)movement)

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DEMYELINATION AREAS

DEMYELINATION AREAS

BRAINBRAIN

SPINAL CORDSPINAL CORD

HALLMARKS OF MS :

HALLMARKS OF MS :

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Imaging of Multiple SclerosisImaging of Multiple Sclerosis Scars from areas of Scars from areas of

demyelinated nervesdemyelinated nerves Sclerotic lesions Sclerotic lesions

throughout nervous systemthroughout nervous system Called MS plaquesCalled MS plaques

MRI is modality of choiceMRI is modality of choice Contrast enhanced can Contrast enhanced can

differentiate active differentiate active inflammation from older inflammation from older brain plaquesbrain plaques

Functional MRI assesses Functional MRI assesses alterations in normal CSF alterations in normal CSF functionfunction

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Multiple Sclerosis: MRIMultiple Sclerosis: MRI

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CT imaging of Multiple SclerosisCT imaging of Multiple Sclerosis

CT shows old inactive diseaseCT shows old inactive disease Well defined areas of decreased attenuationWell defined areas of decreased attenuation

With contrast, in an acute phaseWith contrast, in an acute phase Shows a mixture of decreased density (old)Shows a mixture of decreased density (old) Enhancing regions (active)Enhancing regions (active)

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Treatment for MSTreatment for MS Immunosuppressive Immunosuppressive

agentsagents Limit the autoimmune Limit the autoimmune

attackattack

AntiviralAntiviral Slows the progress of the Slows the progress of the

diseasedisease

Beta interferonBeta interferon Immunomodulatory agents Immunomodulatory agents

that reduce the severity of that reduce the severity of the attacksthe attacks

Given subcutaneouslyGiven subcutaneously

Corticosteroids (short Corticosteroids (short term)term)

Shortens the symptomatic Shortens the symptomatic periodsperiods

Delays progression of Delays progression of diseasedisease

Reduces frequency of Reduces frequency of attacksattacks

Regular exerciseRegular exercise Reduces spasms and Reduces spasms and

increases ROMincreases ROM

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Cerebrovascular Accident (CVA)Cerebrovascular Accident (CVA) Is an atherosclerotic disease affecting blood supply to the Is an atherosclerotic disease affecting blood supply to the

brainbrain 33rdrd leading cause of death in U.S. leading cause of death in U.S. 2 types of stroke:2 types of stroke:

Ischemic and HemorrhagicIschemic and Hemorrhagic Both CT and MRI distinguish between the two typesBoth CT and MRI distinguish between the two types

MRI is especially sensitive to infarction within hours of onsetMRI is especially sensitive to infarction within hours of onset CT, at times appears negative for a day or soCT, at times appears negative for a day or so

Carotid duplex and MRA are also useful in the diagnosis Carotid duplex and MRA are also useful in the diagnosis of a strokeof a stroke

http://www.youtube.com/watch?v=pcmrgwNCPwM&feature=relmfu

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Ischemic StrokeIschemic Stroke Blood clot blocks a blood vessel in the brainBlood clot blocks a blood vessel in the brain Is the majority of strokesIs the majority of strokes

Two types:Two types: Thrombosis of cerebral arteryThrombosis of cerebral artery

• Blood clot that blocks a blood vesselBlood clot that blocks a blood vessel Embolism of the brainEmbolism of the brain

• Is a mass of undissolved matter (solid, liquid or gas) present Is a mass of undissolved matter (solid, liquid or gas) present in a blood vessel brought there by blood currentin a blood vessel brought there by blood current

Diagnosed with CT and MRIDiagnosed with CT and MRI Angiography can be used if other modalites are Angiography can be used if other modalites are

questionablequestionable9393

Symptoms of Thrombotic Symptoms of Thrombotic Ischemic StrokeIschemic Stroke

Sypmtoms come on over horus to daysSypmtoms come on over horus to days ConfusionConfusion HemiplegiaHemiplegia AphasiaAphasia

May be preceded by a temporary episode of May be preceded by a temporary episode of nerurologic dysfunction called transient ischemic nerurologic dysfunction called transient ischemic attack (TIA)attack (TIA) Includes hemiparesis, monocular blindness- clears up Includes hemiparesis, monocular blindness- clears up

in about 2 hoursin about 2 hours

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Ischemic Stroke: from EmbolismIschemic Stroke: from Embolism

Sudden onset of symptoms without warningSudden onset of symptoms without warning

Mortality rate is 20%Mortality rate is 20%

Prognosis depends on location, extent, age, and Prognosis depends on location, extent, age, and general healthgeneral health Complete recovery is rareComplete recovery is rare Deficits remaining after 6 months are likely to be Deficits remaining after 6 months are likely to be

permanentpermanent

TreatmentTreatment Bed rest Bed rest Clot blockers within 3 hours (recombinant tissue Clot blockers within 3 hours (recombinant tissue

plasminogen activator (rtPA)plasminogen activator (rtPA) 9595

Ischemic StrokeIschemic Stroke

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Imaging of Ischemic StrokeImaging of Ischemic Stroke Non-contrast CT scans are most commonly usedNon-contrast CT scans are most commonly used

Before treatment with thrombolytic agentsBefore treatment with thrombolytic agents Best success if within 45 minutes of strokeBest success if within 45 minutes of stroke Follow up CT or transcranial US used after meds to monitor Follow up CT or transcranial US used after meds to monitor

success or medssuccess or meds

MRI is also excellent for imagingMRI is also excellent for imaging In some cases more accurate than CT in identifying EARLY In some cases more accurate than CT in identifying EARLY

infarct signsinfarct signs

CT, MRA and US may offer info regarding patency in the CT, MRA and US may offer info regarding patency in the brain and carotid arteriesbrain and carotid arteries

PET may be used in the future to identify decreased PET may be used in the future to identify decreased Oxygen flow and consumption within the brainOxygen flow and consumption within the brain

Shows promise but not currently used freqentlyShows promise but not currently used freqently

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Hemorrahgic StrokeHemorrahgic Stroke Occurs from a weakening in the diseased blood Occurs from a weakening in the diseased blood

vesselvessel Typically weakened from atherosclerosis from Typically weakened from atherosclerosis from

hypertensionhypertension

Sudden and often lethal because it comes on so Sudden and often lethal because it comes on so suddenlysuddenly

Accounts for 10-15% of all CVA’s Accounts for 10-15% of all CVA’s

Two types:Two types: Subarachnoid and IntracerebralSubarachnoid and Intracerebral

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Hemorrahgic StrokeHemorrahgic Stroke

Most occur in the cerebrum and bleed into Most occur in the cerebrum and bleed into lateral ventriclelateral ventricle

Most often preceded by an intense headache Most often preceded by an intense headache and vomitingand vomiting

LOC follows in minutes and leads to LOC follows in minutes and leads to contralateral hemiplegia or deathcontralateral hemiplegia or death

Prognosis is poorPrognosis is poor 35% die day after stroke35% die day after stroke 15% die within a few weeks, usually from another 15% die within a few weeks, usually from another

vessel rupturevessel rupture9999

Imaging of Hemorrahgic StrokesImaging of Hemorrahgic Strokes

CT is modality of choiceCT is modality of choice Can demonstrate high density blood in the Can demonstrate high density blood in the

subarachnoid space in more than 95% of subarachnoid space in more than 95% of casescases

Can demonstrate aneurysms greaeter than Can demonstrate aneurysms greaeter than 3mm3mm

With contrast is contraindicated because With contrast is contraindicated because surgeon will not operate without an angiogramsurgeon will not operate without an angiogram

MRI is relatively insensitive for MRI is relatively insensitive for subarachoid bleedssubarachoid bleeds

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Treatment ofTreatment ofHemorrahgic StrokesHemorrahgic Strokes

SurgerySurgery Preceded by a surgical angiogramPreceded by a surgical angiogram

If surgical intervention is postponed so will If surgical intervention is postponed so will the angiogramthe angiogram

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Hemorrahgic StrokeHemorrahgic Stroke

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Pathology Summary and Pathology Summary and Modality of ChoiceModality of Choice

Pathology Summary: Central Nervous Pathology Summary: Central Nervous SystemSystem

Pathology Imaging Modalities of Pathology Imaging Modalities of Choice Additive or Subtractive Choice Additive or Subtractive PathologyPathology

Hydrocephalus Hydrocephalus CT, MRI, sonography in the neonateCT, MRI, sonography in the neonate

MeningitisMeningitis MRIMRI

EncephalitisEncephalitis MRIMRI

Brain abscessBrain abscess CT, MRICT, MRI

Herniated nucleus pulposusHerniated nucleus pulposus MRI, CT, myelographyMRI, CT, myelography

Cervical spondylosisCervical spondylosis Radiography SubtractiveRadiography Subtractive Multiple sclerosisMultiple sclerosis

MRIMRI CVACVA

MRI, CT, sonography, PETMRI, CT, sonography, PET

GliomaGlioma MRI, CTMRI, CT

MedulloblastomaMedulloblastoma MRI, CTMRI, CT

MeningiomaMeningioma CT, MRICT, MRI

Pituitary adenomaPituitary adenoma CT, MRICT, MRI

CraniopharyngiomaCraniopharyngioma CTCT

Acoustic neuromaAcoustic neuroma MRIMRI

Spinal tumorSpinal tumor MRI, radiography, CT, myelographyMRI, radiography, CT, myelography

Both Metastases from other sitesBoth Metastases from other sites MRI, radiography, CTSubtractiveMRI, radiography, CTSubtractive

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Documents

CNS Pathology RT 91 Spring 2012 1. INFLAMMATORY DISEASE OF CNS 2