CNS Pathology

RT 91
Spring 2012
1
INFLAMMATORY
DISEASE OF CNS
2
Meningitis
Inflammation fo the meningeal coverings of the brain and
spinal cord

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

Bacterial is most common (can cause hydrocephalus)
Three types pus forming bacteria:
Meningococci - infants
Streptococci - children
Pneumococci- adults

Tubercle bacillus


3
Different Pathogens causing
Meningitis
Fungi
Chronic meningitis
Often associated with AIDS and immunodepressant
drug therapy
Virus
Viral meningitis can be caused by mumps, poliovirus
and herpes simplex
Bacteria
Most common
Bacteria release toxins that destroy meningeal cells
stimulating immune & inflammatory reactions

4
Acute Meningitis
Clinical Symptoms
Fever
Headache
Stiff neck
Vomiting
Changes in LOC
Severely ill in 24 hours
Rash
Chronic symptoms are
the same but occur over
weeks
5
Diagnosis of Meningitis
Brain CT
Rule out contraindications to do a spinal tap

Spinal tap
LP to remove CSF to send to lab

Sometimes MRI is used

Is most sensitive modality for demonstrating pia and
arachnoid

Treatment includes antibiotics and if secondary
to encephalitis: antiviral drugs
6
Radiographic Appearance
Initially meninges
show vascular
congestion, edema
and minute
hemorrhages

MRI and CT scans
could appear normal
if appropriate therapy
is done right away
Meningitis as a result of a Staph infection
7
Encephalitis
Infection of the brain tissue that is viral
May occur subsequent to chickenpox, small
pox, influenza and measles
May be caused by mosquitoes and herpes

Survival rates depend of cause of the
disease (can be fatal)
30% of cases in children
When caused by herpes it is often fatal
8
Encephalitis
MRI is modality of
choice

Results in cerebral
edema and
hemorrhagic lesions

More serious than
meningitis because it
frequently develops
permanent neurologic
disabilities
9
Encephalitis:
Symptoms and Treatment
Symptoms:
Headache

Malaise

Coma

Fever

Seizures

Treatment:
Treated with antiviral
medications

Herpes induced is
treated with Acyclovir
Interferes with DNA
synthesis and inhibits
viral replication
10
CONGENITAL
DISEASES OF CNS
11
Spinal Bifida
Is a congenital disease

Bony neural arch that not completely closed

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

Can range in risk from treatable to life threatening

Can be diagnosed in utero
With amniocentesis
Ultrasound
Elevated beta fetoprotein in mothers blood
12
Types of Spinal Bifida
Meningocele
Only the meninges protrude
Local defect of bone & dura

Myelocele
Protrusion of spinal cord

Meningomyelocele
Protrusion of meninges and
spinal cord into the skin of the
back
Most serious

Spinal bifida occulta
No protrusion of spinal
contents
Least severe
13
Radiographic Appearance
Can be demonstrated
with CT, MRI and
myelography
Prenatally with
ultrasound (in utero)

Large bony defects

Herniated spinal
contents

Meningomyelocele
Meningocele
14
Meningomyelocele
Most serious
Affected PTs have
severe neurologic
deficits
Paraplegia
Diminished control of
lower limbs, bladder
and bowels
Hydrocephalus is
common
15
Spinal Bifida Imaging
16
Spinal Bifida Treatment
Can be surgically repaired
Neurological damage is permanent still and cannot be
reversed

Most measures are supportive rather than
corrective
Physical therapy
Physical supports
Braces
Splints
17
CRANIAL AND SPINAL
FRACTURES
18
Cranial Fractures
Cerebral fractures usually occurs to
fractures of the calvaria of the skull
3 types of cranial fractures
Linear- straight and sharply defined
Is 80% of all cranial fractures

Depressed- curvilinear density

Basilar- Air fluid levels are indicative
Hard to diagnosis radiographically
19
Cranial Fractures
Location of FX is more important that the
extent of the FX
If FX crosses artery a bleed can occur
causing a hematoma

Fx that enters mastoid air cells or sinus can
cause an infection that can result in
Meningitis
Encephalitis

20
Linear Fractures
Non branching lines that
are intensely radiolucent

Vascular markings are
occasionally mistaken for
fractures

Fracture appears more
translucent and
transverses the full
thickness of skull

Sutures
21
Linear Skull FX
22
Depressed Fracture
The fractured edges
overlap

Usually caused by a high
velocity impact with a
small object

Can cause bleeding into
subarachnoid space

Best demonstrated with
CR tangential to the FX
23
Depressed Skull FX
24
Basilar Fracture
Very difficult to demonstrate with x-ray
Air fluid levels in sphenoid sinuses
Clouding of mastoid air cells
Often X-table lateral is done to demonstrate this
CT & MRI are most often used for this type
25
Compression Fracture of spine
Most frequent type of injury involving
vertebral body

Generally occurs in T and L-spine
T11- T12 and T12 L1

Damage is usually limited to the upper
portion of the vertebral body, particularly to
the anterior margin
26
Compression FX of Spine
27
Compression FX of Spine
28
Hangmans Fracture
FX of the arch of the 2
nd
c-spine vertebrae
Usually accompanied by anterior
subluxation of the 2
nd
and 3
rd
cervical
vertebrae
Sometimes called traumatic spondylosis
Resulting from acute hyperextension of
the head & neck
Originally seen commonly in hangings
Now seen more for MVA
29
Hangmans Fracture
30
Hangmans Fracture
31
Jeffersons Fracture
Comminuted FX of the ring of the atlas
First described as a burst FX
Generally occurs as a result of severe axial
force such as a MVA
With this FX particular attn needs to be
paid to the transverse longitudinal
ligament by reviewing lateral masses on
the open mouth odontoid
MRI is preferred method for this ligament


32
Jeffersons Fracture
33
Jeffersons
Fracture
34
TRAUMATIC DISEASE
35
Cerebral Contusion
Is an injury to the brain tissue caused by a
movement of the brain within the calvaria
after blunt trauma

Occurs when brain contacts rough skull
surfaces such as orbital floor and petrous
ridges
PT usually loses consciousness and cannot
remember traumatic event
Persitent LOC over 24 hrs is a coma and can
be fatal
36
CT appearance of
Cerebral Contusion
CT scans appear as low density areas of edema
and tissue necrosis
With or without homogenous density zones reflecting
areas of hemorraghe
Most common sites of injury are frontal and anterior
temporal regions.

When IV contrast is used it will enhance several
weeks after injury
Plays an important role in diagnosis
37
MR of Cerebral Contusion
Cerebral edema causes high signal
intensity on T2 scans

T1 scans may produce high signal regions

Diagnosis can also include CT, MRI and
PET
38
Cerebral
Contusion
Clinical symptoms:
Drowsiness
Confusion
Agitiation
Hemiparesis
Unequal pupil size
Treatment:
PT is hospitalized
Prevent shock

If there is swelling
medication is given to
decrease cranial
pressure

Control edema
Drainage of hematoma

Surgery is usually not
necessary

39
Cerebral Contusion
40
Hematomas
Brain trauma often resulting in a hemorrhaging
from a ruptured vein or artery
Venous bleeding occurs more slowly than arterial
bleeding
Arterial bleed accumulates fast & causes neurologic
symptoms & coma
Both can cause edema in the brain and cause an
increase in intracranial pressure

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

Can result in major consequences & death if not
treated quickly
41
Epidural Hematomas
Highest mortality rate of the hematomas
Even when treated quickly mortality rate is 30%

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

Usually meningeal artery with blood pooling
between bones of the skull & dura mater
http://www.youtube.com/watch?v=cVUofakFIyw&feature=related
42
Epidural Hematoma
Usually a shift of midline
Toward opposite side

CT shows increased
density
Emergency surgical
decompression is required to
relieve cranial pressure
43
Subdural Hematomas
Between the dura mater & arachnoid
meningeal layers
Caused by blunt trauma to frontal or occipital
lobes and can tear subdural veins

Pushes brain away from skull across
midline (including ventricles)

44
http://www.youtube.com/watch?v=qO16QX
MxBLY&feature=related
Subdural Hematoma

Occurs more slowly
Because it is a venous
Hemorrhage.

On CT appears as a
curvilinear area of I
increased density on
portions or all of the
cerebral hemispheres

45
Subdural Hematomas
Subacute stage (up to several days)
Appears on CT as a decreased density or
isodense fluid collection

In chronic state (2-3 weeks)
The surface of the hematoma becomes
concave
Delayed coma con occur
46
Symptoms of Hematomas
Headaches

Agitation

Drowsiness

Gradual radiograph deficits
47
Treatment of Hematomas
In small hematomas without inclination to
rebleed
the hemorrhage is reabsorbed naturally
no treatment is necessary

Severe cases
Require surgical ligation
Evacuation of hematoma to prevent herniation

Less invasive treatment may include
Drug therapy
Intraventricular catheter to remove CSF, which may
cause herniation
48
Degenerative Diseases
49
Herniated Disk
Disks act as shock
absorbers

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

With increased age
the fluid & elasticity
decrease leading to
degenerative disease
and back pain
50
Herniated Disk
May result from either degenerative disease or
trauma

A weakened or torn annulus is subject to rupture
Nucleus pulposus protrudes & compresses spinal
nerve roots
Can prolapse in any direction, sometimes without
pain
When it projects posteriorly there is pain and
weakening of muscles supplied by those nerves
Most commonly occurs is lower cervical & lumbar
Lumbar: Most at L4-L5 and L5 S1
Cervical: Most at C6 C7
Thoracic: T9-T12
51
Herniated Disk
52
Herniated Disk
MRI is modality of choice
CT and Myelography can also be used
53
Symptoms of Herniated Disk
Sudden weak & severe onset of pain
Weakened muscles
Compression of nerve roots in C-spine:
Cause pain and weakness in neck & upper
extremities
Compression in lumbar in L-spine:
Causes pain in hip, posterior thigh, calf and
foot (sciatica)

54
Treatment: Herniated Disk
Conservative treatment:
Bed rest, analgesics and muscle relaxants
Followed by physical therapy
95% recover is 3 months without surgery

Surgical intervention
Diskectomy
Surgical decompression
Spinal fusion
Laminectomy


55
Herniated Disk: Fusion
56
Brain & Spinal
Tumors
57
Spinal Tumors
Primary tumors are less common is spinal
cord than those of the brain
Divided into extradural and intradural
Intradural further divided into
Intramedullary (within spinal cord)
Most common are: Astrocytoma & Epenymoma

Extramedullary (outside spinal cord)
Most common types of primary spinal neoplasm's (>60%)
are: Meningiomas and Neurofibromas
58
Symptoms of Spinal Tumors
Extramedullary

Similar symptoms as a
herniated nucleus
pulposus
Compress nerve roots
leading to pain and
muscle weakness
Intramedullary

Can cause
progressive
paraparesis
Sensory loss
59
Extramedullary Spinal Tumors
Neurofibroma
Meningioma
60
Intramedullary Spinal tumors
Astrocytoma
Ependymoma 61
Imaging of Spinal Tumors
MRI is the modality of choice

Conventional radiography
Can demonstrate bony destruction
Widening of the vertebral pedicles
CT myelo may be necessary to identify
extradural tumors

62
Treatment of Spinal Tumors
Both intramedullary and extramedullary
can be removed surgically
50% of patients who have surgery experience
a reverse of clinical anomalies

In cases where surgery is contraindicated
Radiation therapy is the primary means of
treating a tumor
63
Brain Tumors
Gliomas acct for 50% of all brain tumors
Types of gliomas include: Astrocytoma &
ependymoma
Ependymomas predominate in 3-4 yr olds

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

All tumors have greater incidence in males

Interfere with circulation of the CSF causing a
hydrocephalus
64
Brain Tumors
In children 20% of all tumors are brain
tumors
60 70% are located in the cerebellum &
posterior fossa
Most common are astrocytomas,
medulloblastomas, glioblastomas and
craniopharyngliomas
30% of primary ped. Tumors are medulloblastoma

In adults most prevalent are:
Astrocytomas, glioblastomas, metastatic
tumors and menigiomas
65
Astrocytomas of Brain
Usually treated
with surgery and
radiation therapy
Have good 5
year survival
rate
66
Ependymoma of Brain
Usually treated with surgical removal
67
Medulloblastomas of Brain
68
Craniopharyngliomas of Brain
69
Metastatic Tumor of Brain
70
Meningiomas of Brain
Usually benign

More frequent in women

Rare in children

Less common to see
in brain than spinal cord
71
Symptoms of Brain Tumors
Headache
Nausea and Vomiting
Lethargy
Seizures
Paralysis
Aphasia
Blindness
Deafness
Abnormal changes in personality & behavior
72
Treatment of Brain Tumors
Surgical resection
Radiation therapy

Survival rate for surgery & Radiation therapy
combined is 80% over a 5 year period
Rate of survival decrease to 3% over a
10 year period


73
Hydrocephalus
Can be congenital or acquired
Refers to an excessive amount of fluid in the
ventricles
Two types
Non- communicating
Interferes or blocks normal CSF circulation from the
ventricles to the subarachnoid space
Communicating
Poor absorption of the CSF by the arachnoid Villi
Least common cause is from overproduction of CSF
74
Hydrocephalus
Non-communicating
Can be congenital
Can be from tumor
growth
Trauma (hemorrhage)
Inflammation

Communicating
Can come with
increased cranial
pressure
Raised intrathoracic
pressure impairing
venous flow
Inflammation from
meningitis
Subarachnoid
hemorrhage
75
Radiographic Appearance

Generalized enlargement of the ventricular system

PA radiograph can reveal separation of the sutures

CT clearly demonstrates ventricular dilatation

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

Ultrasound is useful in utero and in infants
Sound waves transverse open fontanels
76
Hydrocephalus
77
Hydrocephalus
78
Hydrocephalus Clinical Symptoms
The cranial size is
enlarged
Scalp veins distended
Skin of scalp thin,
fragile and shiny
Neck muscles
underdeveloped
Severe cases
Orbital roofs are
depressed
Eyes displaced
downwards
In adults
ALOC
Ataxia
Incontinence
Decreased intellectual
capabilities

79
Treatment of Hydrocephalus
Placement of a shunt
Internal jugular, heart or
peritoneum
Contains one way valve to
prevent backflow of blood
into ventricles

Radiographs taken to
verify shunt placement

CT or MRI done to
evaluate success of
treatment


Ventricularjugular Shunt
80
http://www.youtube.com/watch?v=Qmym2i
FVNw8
http://www.youtube.com/watch?v=0h7Xa-
Lsnac
Hydrocephalus in Infants
Affects 1 of every
1000 newborns

Long maturation of
CNS

Can be caused by
maternal & fetal
infections, fetal
hypoxia, irradiation,
chemical agents and
mechanical forces
81
Hydrocephalus In Utero
X-ray used to be taken for fetal age and
position
With hydrocephalic fetus- hard to deliver
vaginally
Pelvimetry was ordered to determine
measurements of inlet and outlet
Very uncomfortable
Three exposures
82
Fetal Hydrocephalus
Communicating
The flow of CSF is free
between ventricles &
subarachnoid space
about cauda equina
Infants head is normal
size but there is
bulging of the frontal
fontanelles
Caused by poor
absorption of CSF
Non-communicating
Obstruction between
ventricles and cauda
equina
Most common form of
obstructive
hydrocephalus is from
abnormalities between
the 3
rd
and 4
th

ventricles
83
Multiple Sclerosis
Chronic progressive disease of the
nervous system
Affects women more than men at approx 20-
40 years of age

There is no cure and its origin is unknown
Treatment only slows the process
Some research indicates it may come from
herpes or retrovirus
Appears more in temperate climates than
tropical climates

84
Multiple Sclerosis
Demyelination of the myelin sheath covering
nervous tissue of spinal cord & white matter
within the brain

It has episodes of relapses and remission

Eventually leads to neurological damage
Impairment of nerve conduction

Patients life is not shortened
Quality of life is diminished
85
Symptoms Of Multiple Sclerosis
Difficulty speaking
clearly

Bladder dysfunction

Muscle impairment

Loss of balance

Poor coordination

Tremors
Muscle weakness

Double vision

Nystagmus (rapid eye
movement)

86
DEMYELINATION AREAS
BRAIN
SPINAL
CORD
HALLMARKS OF MS :
87
Imaging of Multiple Sclerosis
Scars from areas of
demyelinated nerves
Sclerotic lesions
throughout nervous system
Called MS plaques

MRI is modality of choice
Contrast enhanced can
differentiate active
inflammation from older
brain plaques
Functional MRI assesses
alterations in normal CSF
function
88
Multiple Sclerosis: MRI
89
CT imaging of Multiple Sclerosis
CT shows old inactive disease
Well defined areas of decreased attenuation

With contrast, in an acute phase
Shows a mixture of decreased density (old)
Enhancing regions (active)
90
Treatment for MS
Immunosuppressive
agents
Limit the autoimmune
attack

Antiviral
Slows the progress of the
disease

Beta interferon
Immunomodulatory agents
that reduce the severity of
the attacks
Given subcutaneously
Corticosteroids (short
term)
Shortens the symptomatic
periods
Delays progression of
disease
Reduces frequency of
attacks

Regular exercise
Reduces spasms and
increases ROM
91
Cerebrovascular Accident (CVA)
Is an atherosclerotic disease affecting blood
supply to the brain
3
rd
leading cause of death in U.S.
2 types of stroke:
Ischemic and Hemorrhagic
Both CT and MRI distinguish between the two
types
MRI is especially sensitive to infarction within hours of
onset
CT, at times appears negative for a day or so

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

http://www.youtube.com/watch?v=pcmrgwNCPwM&feature=relmfu
92
Ischemic Stroke
Blood clot blocks a blood vessel in the brain
Is the majority of strokes

Two types:
Thrombosis of cerebral artery
Blood clot that blocks a blood vessel
Embolism of the brain
Is a mass of undissolved matter (solid, liquid or gas) present
in a blood vessel brought there by blood current

Diagnosed with CT and MRI
Angiography can be used if other modalites are
questionable
93
Symptoms of Thrombotic
Ischemic Stroke
Sypmtoms come on over horus to days
Confusion
Hemiplegia
Aphasia

May be preceded by a temporary episode of
nerurologic dysfunction called transient ischemic
attack (TIA)
Includes hemiparesis, monocular blindness- clears up
in about 2 hours
94
Ischemic Stroke: from Embolism
Sudden onset of symptoms without warning

Mortality rate is 20%

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

Treatment
Bed rest
Clot blockers within 3 hours (recombinant tissue
plasminogen activator (rtPA)
95
Ischemic Stroke
96
Imaging of Ischemic Stroke
Non-contrast CT scans are most commonly used
Before treatment with thrombolytic agents
Best success if within 45 minutes of stroke
Follow up CT or transcranial US used after meds to monitor
success or meds

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

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

PET may be used in the future to identify decreased
Oxygen flow and consumption within the brain
Shows promise but not currently used freqently
97
Hemorrahgic Stroke
Occurs from a weakening in the diseased blood
vessel
Typically weakened from atherosclerosis from
hypertension

Sudden and often lethal because it comes on so
suddenly

Accounts for 10-15% of all CVAs

Two types:
Subarachnoid and Intracerebral
98
Hemorrahgic Stroke
Most occur in the cerebrum and bleed into
lateral ventricle

Most often preceded by an intense headache
and vomiting

LOC follows in minutes and leads to
contralateral hemiplegia or death

Prognosis is poor
35% die day after stroke
15% die within a few weeks, usually from another
vessel rupture
99
Imaging of Hemorrahgic Strokes
CT is modality of choice
Can demonstrate high density blood in the
subarachnoid space in more than 95% of
cases
Can demonstrate aneurysms greaeter than
3mm
With contrast is contraindicated because
surgeon will not operate without an angiogram

MRI is relatively insensitive for
subarachoid bleeds
100
Treatment of
Hemorrahgic Strokes
Surgery
Preceded by a surgical angiogram

If surgical intervention is postponed so will
the angiogram
101
Hemorrahgic Stroke
102
Pathology Summary and
Modality of Choice
Pathology Summary: Central Nervous
System
Pathology Imaging Modalities of
Choice Additive or Subtractive
Pathology
Hydrocephalus
CT, MRI, sonography in the neonate
Meningitis
MRI
Encephalitis
MRI
Brain abscess
CT, MRI
Herniated nucleus pulposus
MRI, CT, myelography
Cervical spondylosis
Radiography Subtractive
Multiple sclerosis
MRI
CVA
MRI, CT, sonography, PET
Glioma
MRI, CT
Medulloblastoma
MRI, CT
Meningioma
CT, MRI
Pituitary adenoma
CT, MRI
Craniopharyngioma
CT
Acoustic neuroma
MRI
Spinal tumor
MRI, radiography, CT, myelography
Both Metastases from other sites
MRI, radiography, CTSubtractive

103