Imaging Of CNS Infection Workshop - Khon Kaen University

Imaging Of CNS Infection Imaging Of CNS Infection WorkshopWorkshop

Warinthorn Warinthorn PhuttharakPhuttharakDept. Of RadiologyDept. Of RadiologyFaculty Of MedicineFaculty Of MedicineKhonKhon KaenKaen UniversityUniversity

CASE 1CASE 1

Clinical HistoryClinical History

37 year37 year--old male with headacheold male with headachestiff neck : positive stiff neck : positive

LeptomeningitisLeptomeningitis

Inflam.infiltrationInflam.infiltration of of piapia and and arachnoidarachnoid matermaterImaging finding; Imaging finding;

-- Normal ScanNormal Scan-- Enlarged CSF spaceEnlarged CSF space-- Poor visualize basal cisternPoor visualize basal cistern-- Diffuse brain swellingDiffuse brain swelling--*Diffuse *Diffuse meningealmeningeal enhanceenhance-- Communicating Communicating hydrocephhydroceph..

Conditions that produce Conditions that produce leptomeningealleptomeningeal enhancementenhancement

Acute stroke Acute stroke InfectionInfectionInflammatory disease Inflammatory disease egeg. . SarcoidSarcoidMetastases Metastases

Complication of Complication of LeptomeningealLeptomeningeal infectioninfectionArterial infarctionArterial infarctionBasilar adhesionsBasilar adhesionsHydrocephalusHydrocephalusFocal abscess informationFocal abscess informationVentriculitisVentriculitisSubduralSubdural empyemaempyemaEpidural Epidural empyemaempyemaVenous thrombosisVenous thrombosisSubduralSubdural hygromahygromaEncephalomalaciaEncephalomalaciaAtrophyAtrophy

venous thrombosis venous thrombosis Arterial infarctionArterial infarction

SubduralSubdural empyemaempyema, , subduralsubdural hygromahygroma

VentriculitisVentriculitis, , ependymitisependymitis,,choroidchoroid plexitisplexitis

LeptomeningitisLeptomeningitis Vs Vs PachymeningitisPachymeningitis

Different term , different meaningDifferent term , different meaningDifferent imaging findings Different imaging findings ““ PachymeningealPachymeningeal enhancement enhancement ““ : thick and : thick and linear/nodular following the inner surface of the linear/nodular following the inner surface of the calvariumcalvarium, , falxfalx, , tentoriumtentorium and and withoutwithout extension extension into the into the sulcisulci or involvement of the basal cisternor involvement of the basal cistern

LeptomeningitisLeptomeningitis ( Lt.)( Lt.)PachymeningitisPachymeningitis ( Rt.)( Rt.)

Conditions the produce Conditions the produce pachymeningealpachymeningeal enhancementenhancement

CSF LeakCSF LeakIdiopathic Idiopathic hypertrophichypertrophic cranial cranial pachymeningitispachymeningitisInfectionInfectionInflammatory disease Inflammatory disease egeg. . SarcoidSarcoidMetastases including those involving the skullMetastases including those involving the skullPachymeningitisPachymeningitisShuntingShuntingSpontaneous intracranial hypotensionSpontaneous intracranial hypotensionSubarachnoidSubarachnoid hemorrhage hemorrhage

CASE 2CASE 2

40 year40 year--old female , present with old female , present with confusion, behavior change confusion, behavior change

CEREBRITISCEREBRITIS

CEREBRITIS CEREBRITIS

Imaging findings Imaging findings -- NonspecificNonspecific-- Ill defined low density Ill defined low density

areas areas -- Variable Variable gyralgyral

enhancementenhancementSubtle Subtle ------ vividly ( ; vividly ( ;

patchy )patchy )

CASE 3CASE 3

Clinical History Clinical History

A 10 yearA 10 year--old female with urinary tractold female with urinary tractInfection , headaches Infection , headaches

BRAIN ABSCESSBRAIN ABSCESS

AbscessAbscess-- -->>VentriculitisVentriculitis

BRAIN ABSCESSBRAIN ABSCESS

STAGES OF STAGES OF FORMING ABSCESSFORMING ABSCESS

1.1. Early Early cerebritiscerebritis , 4, 4--5 d5 d

2.2. Late Late cerebritiscerebritis , 6, 6--14 d14 d

3.3. Early abscess , 2Early abscess , 2ndnd wk>wk>

4.4. Late abscess , several Late abscess , several wks wks -------- months months

CASE 4CASE 4

Clinical History Clinical History A young female with A young female with

severe headaches, altered severe headaches, altered sensoriumsensorium, , fever, rightfever, right--sided cranial palsy sided cranial palsy

TB Meningitis form TB Meningitis form

CT FINDINGSCT FINDINGS-- -- Diffuse enhancement at Diffuse enhancement at

basal cisternbasal cistern-- -- Progress Progress other other

cisterns including cisterns including sylviansylvianfissure fissure

-- -- Obstructive or Obstructive or communicating communicating hydrocephalus hydrocephalus

HematogenousHematogenous spread from spread from primary focus of infection primary focus of infection elsewhereelsewhere3 3 –– 4 forms ; meningitis form, 4 forms ; meningitis form, Tuberculoma,TuberculousTuberculoma,Tuberculouscerebritiscerebritis/abscess/abscessPresent most freq. as basilar Present most freq. as basilar meningitis meningitis TuberculomaTuberculoma also occur in also occur in the intrathe intra--axial spaceaxial spaceA A cerebritiscerebritis may precede the may precede the development of frank development of frank tuberculoustuberculous abscess in the abscess in the brainbrain

Meningitis form : can cause vascular Meningitis form : can cause vascular compromise, by visible accompanying infarction compromise, by visible accompanying infarction or or vasculitisvasculitis or large vessel occlusion.or large vessel occlusion.A hemorrhagic component to A hemorrhagic component to exudateexudate can can occuroccur

TuberculomaTuberculoma formform

CT FINDINGSCT FINDINGSNCCT : NCCT : IsodenseIsodense or slightlyor slightlyHyperdenseHyperdense nodules nodules

CECT : Homogeneous CECT : Homogeneous nodular enhancement nodular enhancement or ring enhancement or ring enhancement

CASE 5CASE 5


A 42A 42--yearyear--old female withold female with7 d PTA ; URI symptoms7 d PTA ; URI symptoms3 d PTA ; high grade fever with 3 d PTA ; high grade fever with acute mental status change & memory lossacute mental status change & memory lossfollowed rapidly by stupor followed rapidly by stupor

Low density areas at Low density areas at both temporal lobes both temporal lobes and both frontal bases and both frontal bases

with evidence of with evidence of intraparenchymalintraparenchymal bleed / bleed / hemorrhage hemorrhage

*** Spared basal ganglia*** Spared basal ganglia

Herpes simplex encephalitisHerpes simplex encephalitis

Uncommon, potentially Uncommon, potentially fatal fatal ……butbut……can treated can treated with Acyclovirwith AcyclovirRapid Rapid DxDx. and . and Rx.Rx. crucialcrucial for for optimum outcomeoptimum outcomePatho.Patho. hemorrhagichemorrhagicnecrosis involving one or necrosis involving one or both temporal lobesboth temporal lobes

Herpes encephalitisHerpes encephalitis

CT CT NECT: low density area at NECT: low density area at

temporal lobe, inferior temporal lobe, inferior frontal lobe ( spare BG)/ frontal lobe ( spare BG)/ hemorrhagehemorrhage

CECT: CECT: GyralGyral enhancementenhancement

Herpes encephalitisHerpes encephalitis

MRI : High intensity on MRI : High intensity on T2W in temporal , T2W in temporal , inferior frontal (inferior frontal (insulainsula, , hippocampus) , hippocampus) , cingulatecingulategyrigyri

Diff. Diff. DxDx..

Bilat.temporalBilat.temporal lobe infarctionlobe infarctionTemporal Temporal gliomaglioma/ / gliomatosisgliomatosis

Strong Clues : Acuteness of symptom onset and Strong Clues : Acuteness of symptom onset and rapidly progression of disease rapidly progression of disease

CASE 6CASE 6


A 35A 35--yearyear--old male , old male , immunocompromisedimmunocompromisedPatient with altered mental status.Patient with altered mental status.

CRYPTOCOCCOSISCRYPTOCOCCOSISmeningitis/encephalitis,meningitis/encephalitis,

GranulomaGranuloma formationformationRecognition:Recognition:** dilated ** dilated perivascularperivascular spaces in young spaces in young

immunocompromisedimmunocompromised pt.pt.---- possibility of possibility of cryptococcuscryptococcus** Dilated spaces filled with gelatinous ** Dilated spaces filled with gelatinous

cysts,incysts,in and adjacent to basal and adjacent to basal ganglia /ganglia /corticomedullarycorticomedullary jnjn. . ( may / may not enhance)( may / may not enhance)

** multiple ** multiple miliarymiliary enhancing enhancing parenchymalparenchymal + + leptomeningealleptomeningealnodules with involved nodules with involved choroidchoroidplexus in the plexus in the trigonetrigone

Other less common: widening basal Other less common: widening basal cistern, hydrocephalus, diffuse cistern, hydrocephalus, diffuse atrophyatrophy

**Gelatinous **Gelatinous form,cryptoform,crypto ( LT.)( LT.)

CryptococcomaCryptococcoma ( RT. )( RT. )

Multiple Multiple miliarymiliary enhancing nodulesenhancing nodules

CASE 7CASE 7

Clinical HistoryClinical History

Male 38 yrMale 38 yr--old with severe headacheold with severe headache

AspergillosisAspergillosis

Entry CNS : Entry CNS : hematogenoushematogenous spread from lung or spread from lung or direct extension from PNSdirect extension from PNSInvolved brain in aggressive form Involved brain in aggressive form -- --> meningitis, > meningitis, meningoencephalitismeningoencephalitis ––hemorrhagic infarction hemorrhagic infarction Aggressive form : invasion of blood vessels with Aggressive form : invasion of blood vessels with secondary thrombosis / infarction ***secondary thrombosis / infarction ***Less aggressive ; isolated brain abscess, Less aggressive ; isolated brain abscess, granulomagranuloma

CASE 8CASE 8


Male 34 yrMale 34 yr--old ,present with old ,present with first time seizure first time seizure

Another case, same Another case, same diagdiag..

DxDx; Colloidal vesicular ; Colloidal vesicular stage , stage , NeurocysticercosisNeurocysticercosis

Case 8Case 8

NeurocysticercosisNeurocysticercosis


Pork tapeworm , larva is carried to the brain Pork tapeworm , larva is carried to the brain through through hematogenoushematogenous route route Inflammatory response when larva diesInflammatory response when larva dies

And then And then …………calcification calcification *** The inflammatory stage is nonspecific, *** The inflammatory stage is nonspecific,

generally generally subcorticalsubcortical region , may simulate region , may simulate neoplasm or other infection neoplasm or other infection

; but with calcification, the ; but with calcification, the diagdiag. become easier.. become easier.


4 forms : 4 forms : ParenchymalParenchymal, , cisternalcisternal, , IntraventricularIntraventricular and spinal and spinal cysticercosiscysticercosis5 stages 5 stages

1.1. Acute stageAcute stage2.2. Vesicular stage Vesicular stage 3.3. Colloidal vesicular stageColloidal vesicular stage4.4. Nodular stage Nodular stage 5.5. Nodular calcified stage Nodular calcified stage

Cyst withScolex4.nodular stage

2.Vesicularstage

5.Nodular calcifiedstage

CisternalCisternal form( form( racemoseracemose cysticercuscysticercus))

CASE 9CASE 9


43 year43 year--old male ,AIDS with old male ,AIDS with altered mental status altered mental status

ToxoplasmosisToxoplasmosis

Intracellular protozoa :Intracellular protozoa :ToxoplasmaToxoplasma gondiigondiiPathoPatho: severe necrotizing : severe necrotizing

encephalitis & encephalitis & vasculitisvasculitisLesions : basal ganglia, Lesions : basal ganglia, WM,CorticomedullaryWM,Corticomedullary jnjn..Low density lesions Low density lesions +nodular/ ring enhance+nodular/ ring enhance

/target like lesions + edema /target like lesions + edema ( ( multiple,bilateralmultiple,bilateral hemispheric hemispheric

lesions )lesions )

ToxoToxo Vs LymphomaVs Lymphoma

Tempting to Tempting to DDxDDx. : different Rx.. : different Rx.Possible clues to distinguish Possible clues to distinguish -- Number and size : abscess of Number and size : abscess of toxotoxo tend to be tend to be more number, smaller in size more number, smaller in size -- Location : not help ( although Location : not help ( although toxotoxo. Location : . Location : BG, doesnBG, doesn’’t spread in t spread in periventricularperiventricular or involve or involve ependymaependyma ))-- Hemorrhage : Hemorrhage : ToxoToxo. More hemorrhage . More hemorrhage

ThalliumThallium--201 SPECT : for lymphoma201 SPECT : for lymphomaMR perfusion : increased perfusion in MR perfusion : increased perfusion in lymphoma , decreased in lymphoma , decreased in toxotoxo..1H MRS : 1H MRS :

ToxoToxo ; marked elevation of lactate ,lipid conc.; marked elevation of lactate ,lipid conc.Lymphoma ; moderate Lymphoma ; moderate ““----------------------------------””, increased , increased

CholineCholine peak peak

CASE 10CASE 10

34 year34 year--old male old male AIDS with alternation of consciousAIDS with alternation of conscious

HIV encephalopathyHIV encephalopathy

Primary HIV infectionPrimary HIV infectionPathoPatho : diffuse viral infection at : diffuse viral infection at centrumcentrumsemiovalesemiovale, cortex and basal ganglia , brain stem , cortex and basal ganglia , brain stem

( ( demyelinationdemyelination, vacuolization, WM necrosis ) , vacuolization, WM necrosis ) CT : Progressive brain atrophy, ventricular enlargeCT : Progressive brain atrophy, ventricular enlargeHypodensityHypodensity of WM (MR is more sensitive) of WM (MR is more sensitive) MR : MR : HyperintensityHyperintensity of of periventricularperiventricular WM WM

CASE 11 CASE 11

40 year40 year--old male old male AIDS present with altered mental status, AIDS present with altered mental status, patient die within 6 months of clinicalpatient die within 6 months of clinicalonset onset

Progressive Progressive multifocalmultifocalleukoencephalopathyleukoencephalopathy ( PML)( PML)

DNA DNA papovaviruspapovavirus serotype JCserotype JC4% of AIDS patients 4% of AIDS patients Lesions : cerebrum ( frontal lobe, Lesions : cerebrum ( frontal lobe, parietoparieto--occipital regions) , cerebellum , brain stem occipital regions) , cerebellum , brain stem Infect Infect oliogodendrocyteoliogodendrocyte -- -->>multifocalmultifocaldemyelinationdemyelination + WM necrosis + WM necrosis Pt.alwaysPt.always die within 6 months of clinical onset die within 6 months of clinical onset of disease of disease

PMLPML

ThanksThanksfor for

your attentionyour attention

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Imaging Of CNS Infection Workshop - Khon Kaen University

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