Pediatric Emergency Brain Imaging Pearls and Pitfalls - SPR
Transcript of Pediatric Emergency Brain Imaging Pearls and Pitfalls - SPR
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Beyond Trauma: Pediatric Emergency Brain Imaging Pearls and Pitfalls
Laura Z. Fenton, MD
Associate Professor
SPR 2013
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I have no disclosures
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SAM : 10 you girl with lymphoma and altered mental status, what is the most likely cause of the
parasagittal hemorrhage?
• A. Hemorrhagic lymphoma
• B. Vascular Malformation
• C. Venous Thrombosis
• D. Arterial ischemic stroke
• E. Chemotherapy
Rt ML
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Emergency Pediatric brain imaging: balance speed, radiation & cost
• Brain CT (mainstay)
–*ALARA
• Non- radiation alternatives:
–Brain US (neonate and infant)• Bleed, ventricles, Doppler
–Fast Brain MRI (T2 3 plane)
• Shunt malfunction
• Extra-axial collection
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Pediatric Emergency Brain Imaging
• Cerebral venous thrombosis
• Hemorrhage
• Cerebral Edema
• Acquired Infection
• Acute disseminated encephalomyelitis
• Shunt Malfunction
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Cerebral Venous Thrombosis (CVT): often a challenging diagnosis
• Unlike AIS, CVT diagnosis by identification of the thrombus
– less common parenchymal edema & hemorrhage
• Often not anticipated clinically
–*In DDX in 5% of ordered CTs and 33% of MRIs
• Nonspecific clinical features
* Provenzale JM, Kranz PG. Dural Sinus Thrombosis: Sources of
Error in Image Interpretation. AJR 2011; 196: 23-31.
transverse sinus thrombus
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Clinical Features of CVT
• Symptoms
–Headache (75-95%)
–Visual change
–Altered consciousness
–Nausea, vomiting
• Symptom onset
– Subacute: 55% (6-30d)
– Acute: 10-30% (0-5 d)
– Chronic: 15% (> 30d)
• Signs
–Papilledema
– Focal neurol deficit
–Cranial nerve palsy
– Seizure
–Coma
Therefore imaging plays a
primary role in diagnosis!
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Predisposing Factors for Cerebral Venous Thrombosis (CVT)
• Systemic:
–Dehydration
–Hypercoagulable state
• Thrombophilia: Protein C or S deficiency
• Malignancy
– Systemic Infection/inflammation (IBD)
– Surgery/immobilization
– Pregnancy or Oral contraceptive use
• Local: intracranial trauma or infection
• Idiopathic (12-25%)
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
–CT: Hyperdense sinus (20%)
• Indirect: parenchymal
SSS
thrombosis
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Cerebral Venous Thrombosis
• Hyperdense sinus DDX
–Thrombus (20%)
Right Sigmoid sinus thrombosis
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Cerebral Venous Thrombosis: pitfalls on CT
• Hyperdense sinus DDX
–Thrombus (20%)
–Hemoconcentration
• *neonate
Normal
newborn
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Cerebral Venous Thrombosis: pitfalls on CT
• Hyperdense sinus DDX
–Thrombus (20%)
–Hemoconcentration
• *neonate
–Subjacent hemorrhage
•Birth related SDH
Subgaleal
hematoma
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Parturitional SDH is common!
• 101 asymptomatic term neonates
• Both vaginal and cesarean deliveries
• Brain MRI & US at 3-7d, 1 mo & 3 mo
• 46% had small (most < 3mm) SDH– All supratentorial, 20% + infratentorial
– Most resolved by 1 mo, all by 3 mo
– Higher incidence than previously (8-10%)
• All had normal development at 24 mo
Rooks VJ, Eaton JP, Ruess L et al. Prevalence and evolution of Intracranial
Hemorrhage in Asymptomatic Term Infants. AJNR. June 2008 29: 1082-1089.
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
– CT: Hyperdense sinus (20%)
–CT: Cord sign (5%)
• Indirect: parenchymal
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
– CT: Hyperdense sinus (20%)
– CT: Cord sign (5%)
–CT and MRI post contrast:
• Empty delta sign (70%)
• Indirect: parenchymal
SSS and TS Thrombosis
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
– CT: Hyperdense sinus (20%)
– CT: Cord sign (5%)
– CT and MRI post contrast:
• Empty delta sign (70%)
–MRI: subacute T1 & T2 bright
• Indirect: parenchymal
Newborn: Left TS thrombosis
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Cerebral Venous Thrombosis : MRI
Acute (0-5 d) Subacute (6-30d) Chronic (>30d)
T1 Isointense increased isointense
T2 decreased increased Iso- increased
GRE decreased decreased decreased
(deoxyhemoglobin) (methemoglobin) (variable)
*mimics normalflow
*easiest to see on MRI
*slow flow*collaterals
10-30% of cases 55% of cases
Signal Relative to gray matter
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Cerebral Venous Thrombosis : MRI
Acute (0-5 d) Subacute (6-30d) Chronic (>30d)
T1 Isointense increased isointense
T2 decreased increased Iso- increased
GRE decreased decreased decreased
(deoxyhemoglobin) (methemoglobin) (variable)
*mimics normalflow
*easiest to see on MRI
*slow flow*collaterals
10-30% of cases 55% of cases
Signal Relative to gray matter
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
– CT: Hyperdense sinus (20%)
– CT: Cord sign (5%)
– CT + and MRI post contrast:
• Empty delta sign (70%)
– MRI: subacute T1 & T2 bright
–MRI: blooming on GRE/SWI
• Indirect: parenchymal
Acute Rt TS thrombosis
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Imaging of Cerebral Venous Thrombosis
• Direct: clot
– CT: Hyperdense sinus (20%)
– CT: Cord sign (5%)
– CT + and MRI post contrast:
• Empty delta sign (70%)
– MRI: subacute T1 & T2 bright
– MRI: blooming on GRE
• Indirect: parenchymal (41-57%)
– Focal edema/hemorrhage
– Restricted diffusion: 50% with inc T2Where is the thrombosed vein?
21
3
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Cerebral Venous Thrombosis: parenchymal abnormality locations
• Superior Sagittal Sinus: parasagittal frontal & parietal lobes
• 1DWI ADC
16 yo female on OCP with acute LLE weakness: acute SSS thrombosis
GRET1 T2
1
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Cerebral Venous Thrombosis: parenchymal abnormality locations
• Transverse Sinus or vein Of Labbe:
temporal lobe
Courtesy of Dr. David MirskyAcute left transverse sinus thrombosis
2
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Cerebral Venous Thrombosis: parenchymal abnormality locations
• Deep Cerebral Veins:
– Straight Sinus
–Vein of Galen (VOG)
– Internal Cerebral Veins
thalami
DWIT2
Acute VOG thrombosis
Courtesy of Dr. David Mirsky
T1
3
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Cerebral Venous Thrombosis : pitfalls
• Variant venous anatomy
–Arachnoid granulation
7yo boy with headache
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Arachnoid Granulation
• Common!
– Up to 90% on 3D GRE
• SSS , TS > SS
• Round, contain septa, scalloping of adjacent inner table
• Follows CSF–CT: low density
– MRI: T1 hypointense
T2 hyperintense
2 different patients
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Arachnoid Granulation
• Common!
– Up to 90% on 3D GRE
• SSS , TS > SS
• Round, contain septa, scalloping of adjacent inner table
• Follows CSF–CT: low density
– MRI: T1 hypointense
T2 hyperintense
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Cerebral Venous Thrombosis : pitfalls
• Variant venous anatomy
– Arachnoid granulation
• MRI:
– Slow/turbulent flow
4yo with cerebellitis
T2 Flair
T1 postT1 pre
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Cerebral Venous Thrombosis : pitfalls
• Variant venous anatomy
– Arachnoid granulation
• MRI:
– Slow or turbulent flow
– Increased T1 thrombus signal on post gad
7 yo with thalamic astrocystoma and subacute SSS thrombosis
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Cerebral Venous Thrombosis : pearls
• Look at “edges” of CT
– superior sagittal, transverse and sigmoid sinuses
Hyperdense sinus and cord signs
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Cerebral Venous Thrombosis : pearls
• Look at “edges” of CT
– Superior Sagittal, Transverse and sigmoid sinuses
• GRE and SWI: paramagnetic effect in acute & subacute phases
GRE
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Cerebral Venous Thrombosis : pearls
• Look at “edges” of CT
– Superior Sagittal, Transverse and sigmoid sinuses
• GRE and SWI: paramagnetic effect in acute & subacute phases
• Doppler US in neonates
Normal neonate SSS
Neonate with SSS thrombosis
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Is this just slow flow in right transverse sinus?
Term newborn with meconium aspiration,
MRI following ECMO and head cooling
Mastoid view
Yes, normal flow on US
Right TS
GRE
T2
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16 day old term baby with seizure
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Deep Medullary Vein Thrombosis
• Cause of hemorrhage and white matter injury
in term neonates
• In absence of venous sinus thrombosis
• Periventricular T2 hypointense linear or fan shaped
• Frontal predominanceArrigoni F,et al. Deep medullary vein involvement in neonates
with brain damage: An MRI study. AJNR 2011 32: 2030-36.
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Sphenoid sinusitis with bilateral cavernous sinus thrombosis
Age matched normal
comparison
Left proptosis
Left sphenoid AFL
Expanded and
nonenhancing
cavernous sinuses
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Cavernous sinus thrombosis
• Secondary to paranasal sinus, dental or ocular infection
• CT: enlarged, outwardly convex cavernous sinus
• MRI: signal varies depending on cause and evolution
• ** cavernous carotid artery: stenosis, mycotic aneurysm
–MRA or CTA
Post gad T1 FS
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16 yo boy with N/V, HA, dizzy
T1 pre T1 post
T2 GRE
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16 yo boy with N/V, HA, dizzy
T1 pre T1 post
T2 GRE
Cavernous Malformation
Hemosiderin rim
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Cerebral Cavernous Malformation (CCM)
• Hypertrophied capillary beds containing pockets of blood
• Familial and sporadic – KRIT1 (CCM1), CCM2 & CCM3 genes
• Imaging: without acute bleed:
– CT: hyperdense mass
– MRI: prior hemorrhage
• Hemosiderin: blooming GRE
• “popcorn” T1 hyperintensity
• Heterogeneous on T1 & T2 13yo boy with seizure
Left frontal CCM
T1
GRET2
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Familial CCM: 5 mo boy with macrocephaly and tense fontanelle
• Gene mutation KRIT1 (CCM1) on 7q
– 50% multiple if familial (13% if sporadic)
• Consider CCM as cause of small hemorrhage (<3cm)
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Nontraumatic Pediatric Brain Hemorrhage: Etiology
• *3 series, each > 50 children
• Vascular anomaly majority for all series (28-62%)
–Cavernoma, AVM/F, aneurysm
• Coagulopathy 2nd most common (18-32%)
– Thrombocytopenia
• Tumor (10-15%)
–Medulloblastoma/PNET, high gr astrocytoma
• *1. Warren D.Lo et al. Arch Neurol 2008 65: 12
• 2. Liu Andrea C Y et al. Pediatr Radiol 2006: 36
• 3. Al-Jarallah et al. J Child Neurol 2000: 15:284
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9 yo girl with sudden onset of HA and vomiting followed by lethargy
T1 pre T1 post
CTA: vascular nidus & draining vein
Cerebellar AVMIn children <15 yrs:
AVM is the most
common cause of
spontaneous
intracranial
hemorrhage
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13yo girl found down
Left M2 branch
6mm aneurysm
“nipple”
CTA
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Cerebral Herniation
SubfalcineDescending
Transtentorial (Uncal)
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Term newborn with coarctation and cleft lip/palate, preop head US
GMH, IVH, SAH
Coagulopathy due to
Factor VII deficiency
-hemophilia
-brain, GI, MSK bleed
(may be life threatening)
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6 yo girl with 2 weeks ofintermittent HA, ataxia, emesis
• Medulloblastoma
– WHO IV
– Most common malignant brain tumor in children (15-20%)
• Most common to present with hemorrhage
– Most common posterior fossa tumor (30-40%) in most series
T1 post
T1 pre
T2
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3yo girl with vomiting and lethargy: Diffuse Cerebral Edema
Deep gray matter edema
Effacement of Suprasellar
perimesencephalic &
prepontine cisterns
Bright cerebellum
Diffuse sulcal effacement
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Cerebral edema
• Protean causes
– Drowning or near drowning
– Infection: septic shock
– Hepatic encephalopathy
– Uremic encephalopathy
– Diabetic ketoacidosis
– Status epilepticus
– Metabolic derangement
– Toxin
– Trauma
Severe cerebral edema
Salicylate toxicity
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Cerebral edema
• Protean causes
–Common thread: disruption of cerebral autoregulation
• Challenging CT: symmetric and subtle early changes
• Brain CT: scrutinize:
–Deep gray matter
– Sulci
–Cisterns
–Cerebellar density
Severe cerebral edema
Salicylate toxicitymost reliable
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Transient cerebral edema due to encephalopathy following GI illness
Normal CT 1 yr ago Vertex sulcal effacement 1 day later:
normalized sulci
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ARS: 20 month old drowning victim, what is the prognosis?
• A. Good
• B. Fair
• C. Dismal
• D. Uncertain
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ARS: 20 month old drowning victim, what is the prognosis?
• A. Good
• B. Fair
• C. Dismal
• D. Uncertain
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Reversal Sign on CT
• Severe diffuse anoxic/ischemic cerebral injury
• Supratentorial gray matter is darker than white matter
–Relative increased density of basal ganglia
• Poor prognosis, irreversible brain damage
– Series of 20 children (40% died, rest with profound deficit)
Han BK et al. AJNR 1989 10: 1191-1198
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US analogue of reversal sign: diffuse cerebral edema
2 week old baby with complex CHD & coagulopathy
Normal US for
comparison
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9 yo girl with vomiting, fever & seizure
• Diffuse cerebral edema:
–Bilateral uncal herniation
–Obliteration of the perimesencephalic cistern
–Diffuse sulcal effacement
–Bright cerebellum
–BUT deep and superficial gray-white differentiation preserved
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9 yo girl with vomiting, fever & seizure
FLAIR
T1 post
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9 yo girl with vomiting, fever & seizure
Cerebral edema due do
Mycoplasma Meningitis
FLAIR
T1 post
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Acquired Brain Infection:Meningitis, Empyema, Cerebritis, Abscess
• Etiology
–Hematogenous
• Neonates, infants
–Local Extension
• Child/adolescent
–Paranasal sinus
–Otomastoid
– Other: postop, trauma10 yo boy with headache:
acute sinusitis with epidural abscess
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10 yo boy with headache and altered mental status
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Complicated sinusitis with meningitis and epidural abscess
DWIFLAIR
T2
T1 postT1 pre
ADC
Epidural abscess may be remote from
infected sinuses
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Meningitis complications
• Effusion
• Empyema
• Cerebritis
• Ventriculitis
• Abscess
• Hydrocephalus
• Venous thrombosis
• Arterial Vasculopathy
All may be life threatening
Neonate with
E. Coli meningitis
Diffuse meningeal
enhancment
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6 month old with fever and dyscongugate gaze
Post-contrast
Post
Gad
T1
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Meningitis complications: Effusion vs Emypema
• Subdural or subarachnoid
– Rarely epidural
• Group B strep, E. Coli, S. pneumoniae
– Rarely H Flu (vaccine)
• Frontal-parietal-temporal
– Convexity > parafalcine
– Loculated by MRI in 50%
• Distinguish on DWI
– Empyema: restricted
DWI
ADC
Subdural effusion
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4 month old with group B Strep meningitis and lethargy
T1 pre T1 post
ADC
DWI
Restricted diffusion
Subdural empyema
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2 yo girl with seizure and altered mental status
T1
FLAIRT2
Post T1
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Meningitis complications: Cerebritis (encephalitis)
• Earliest stage of purulent brain infection
– Bacterial or viral (HSV)
• With empyema in 20%
• Imaging: ill-defined edema on US, CT or MRI
• Resolves with Abx or evolves to abscess
• DDX ischemia due to venous or arterial occlusion HSV meningoencephalitis
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3 week old girl with seizures and poor feeding
DWI
ADC
Neonatal herpes simplex encephalitis
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Neonatal vs Child/adolescent Herpes Simplex Encephalitis (HSV)Neonatal (HSV 2)
• Hematogenous
• Widespread
• Watershed pattern (40%)
Child (HSV 1)
• Reactivation of latent
• Medial temporal lobe, cingulum and insula
DWI
FLAIR
ADCDWI
Both require a high index of suspicion
May mimic infarction- especially in neonate
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4 month old with macrocephaly and tense fontanelle
Brain abscess
Staph AureusThis infant was treated with
trans-fontanelle needle drainage
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Brain Abscess
• Large at diagnosis
• Poor capsule formation
– Often incomplete
• Begin in periventricular white matter
• Small at diagnosis
• Capsule formation 7-14 d
• Begin in subcortical white matter or Basal ganglia
NEONATE CHILD (similar to adult)
4 month old12 year old
DWIT1 post
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Brain Abscess: Risk factors in children
• Paranasal sinus or otomastoid infection
• Congenital heart disease
• Endocarditis
• Sepsis
• Pulmonary infection
• Immunodeficiency or immunosuppression
• Head or neck trauma
ADC
T1 postT1 pre
T2
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Brain abscess: child7 year old girl with headache and vomiting
Strep anginosus, undiagnosed PFOT2 T1 post
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Brain Abscess Imaging
• Capsule thicker on cortical side (increased vascularity)
• DWI to distinguish cystic/necrotic tumor:
– Abscess: restricted
– Nec tumor : increased
– BUT: if aspiration performed, susceptibility from blood (use GRE, SWI) Restricted diffusion
infant with right gaze preference
T1 post T2
DWIADC
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14 month old boy: vomiting & lethargyT1 post gad
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14 month old boy: vomiting & lethargy
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Tuberculous Meningitis
• *Family member with TB
• Intense basilar cistern meningeal reaction
–Hydrocephalus (50-75%)
–Vasculitis
– Infarction: BG, thalamus
• Imaging: improved conspicuity
– Delayed post Gad (5 min)
– Post contrast FLAIR
**DWI not reliable (conflicting)
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9yo girl with HA, vomiting, confusion
• Multifocal asymmetric subcortical white matter and deep cerebellar white matter hypodensity DDX:
• - ADEM(Acute Disseminated EncephaloMyelitis)
• - Viral encephalitis
• - Multiple sclerosis
• - Neurosarcoidosis
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9yo girl with HA, vomiting, confusion: ADEM
FLAIR
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ADEM
• Autoimmune
– Post viral, vaccine > > bacterial (mycoplasma), drug
• Deep gray matter lesions 50%
• Brain stem and cerebellar lesions (each 30-50%)
• Spinal cord involvement 24%
• Rx: steroids, 70-90% complete recovery
• 25% later DX: MS (>10Y)
•
11yo girl
ADEM
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Fussy and lethargic 7mo old
Baseline 4mo
Trapped 4th
ventricle
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Trapped 4th Ventricle
• Chronic sequela of shunt
• Rare: incidence 2.3-3%
• Due to repeated hemorrhage/infection leading to scarring of cerebral aqueduct and foramina of Magendie and Luschka
• *Fast MRI: visualize aqueduct
• Mass effect on brainstem
• Treatment: 2nd catheter 6mo after 4th ventricle shunt
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Shunt malfunction
• Common: incidence:
– 14% 1st mo; 50% 1st year
Causes:
• 1. obstruction (most common)
• 2. breakage (2nd)
• 3. infection (3rd)
• 4. slit ventricle syndrome (rare)
• 5. malposition or migration
Sivaganesan A. Neuroimaging of ventriculoperitoneal shunt
complications in children. Pediatr Radiol (2012) 42: 1029-1046.
Baseline: tectal glioma with shunt
Fast T2
Shunt obstruction
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Shunt malfunction: Imaging Evaluation
• Brain US- neonate and infant
• Brain CT: change in ventricle size
– Temporal horn 1st; Occipital horn in infants
• “Quick brain MRI” : 3 plane fast T2
– As sensitive as CT in diagnosis, no radiation
– **must re-evaluate valve setting after MRI
• Radiographic shunt series (highest yield if swelling along shunt tract): discontinuity, kink, migration; **sutural diastases, wide sella
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14 yo girl with HA, pain along shunt
6 mo ago
Shunt series: intact,
non-radiopaque valve
noted…
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Disconnection just below valve diagnosed by fast MRI
6 mo ago
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Pediatric Emergency Brain Imaging
• Cerebral venous thrombosis
• Hemorrhage
• Cerebral Edema
• Acquired Infection
• Acute disseminated encephalomyelitis
• Shunt Malfunction
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SAM : 10 you girl with lymphoma and altered mental status, what is the most likely cause of the
hemorrhage?
• A. Hemorrhagic lymphoma
• B. Vascular Malformation
• C. Venous Thrombosis
• D. Arterial ischemic stroke
• E. Chemotherapy
Rt ML
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SAM : 10 you girl with lymphoma and altered mental status, what is the most likely cause of the
hemorrhage?
• A. Hemorrhagic lymphoma
• B. Vascular Malformation
• C. Venous Thrombosis
• D. Arterial ischemic stroke
• E. Chemotherapy
Rt ML
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Superior Sagittal SinusThrombosis
• Risk factor: lymphoma
– Hypercoagulable state
• MRI: T1 and T2 hyperintense clot
– Subacute
• Typical infarct location: paramedian
GRE
T1 Post gad T1 T2
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Thank you for your attention!
Enjoy San Antonio!
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References for SAM
• 1. Provenzale JM and Kranz PG. Dural sinus thrombosis: sources of error in image interpretation. AJR 2011; 196: 23-31
• 2. Leach JL, Fortuna RB, Jones BV et al. Imaging of cerebral venous thrombosis: current techniques, spectrum of findings and diagnostic pitfalls. Radiographics 2006; 26: S19-S43.
• 3. Rodallec MH, Krainkik A, Feydy A et al. Cerebral venous thrombosis and multidetector CT Angiography: Tips and Tricks. Radiographics 2006; 26: S5-S18.
• 4. Slone HW, Blake JJ, Shah R et al. CT and MRI findings of intracranial lymphoma. AJR 2005; 184: 1679-1685.