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

 Survivalrates 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
 Treatment:
Symptoms:
 Headache
Treated with antiviral medications


 Herpes
Malaise induced is treated with Acyclovir
• Interferes with DNA synthesis and inhibits viral
replication
 Coma

 Fever

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 CONGENITAL
DISEASES OF CNS

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 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 mother’s blood

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 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 13
 Least severe
 Radiographic Appearance
Meningomyelocele

 Can be demonstrated
with CT, MRI and
myelography
 Prenatally with
ultrasound (in utero)
Meningocele

 Large bony defects

 Herniated spinal
contents

14
 Meningomyelocele
 Most serious
 Affected PT’s have
severe neurologic
deficits
 Paraplegia
 Diminished control of
lower limbs, bladder
and bowels
 Hydrocephalus is
common

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Spinal Bifida Imaging

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 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

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CRANIAL AND SPINAL
FRACTURES

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 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
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 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

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 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
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Linear Skull FX

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 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
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Depressed Skull FX

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 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
 Mostfrequent 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
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Compression FX of Spine

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Compression FX of Spine

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 Hangman’s Fracture
 FX of the arch of the 2nd c-spine vertebrae
 Usually accompanied by anterior
subluxation of the 2nd and 3rd cervical
vertebrae
 Sometimes called traumatic spondylosis
 Resulting from acute hyperextension of
the head & neck
 Originally seen commonly in hangings
 Now seen more for MVA

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Hangman’s Fracture

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Hangman’s Fracture

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 Jefferson’s 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

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Jefferson’s Fracture

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Jefferson’s
Fracture

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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  Treatment:
Contusion  PT is hospitalized
• Prevent shock

 Clinical symptoms:
 If there is swelling
medication is given
 Drowsiness
to decrease cranial
 Confusion pressure
 Agitiation
 Hemiparesis • Control edema
 Unequal pupil size • Drainage of
hematoma

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Cerebral Contusion

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 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
Emergency surgical
CT shows increased decompression is required to
density relieve cranial pressure 43
 Subdural Hematomas
 Betweenthe 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)
http://www.youtube.com/watch?v=qO16QX
MxBLY&feature=related

44
 Subdural Hematoma

Occurs more slowly On CT appears as a

Because it is a venous curvilinear area of I
Hemorrhage. 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 48
cause herniation
Degenerative Diseases

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 Disks act as shock
Herniated Disk
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

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Herniated Disk

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 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)

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 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
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Herniated Disk: Fusion

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Brain & Spinal
Tumors

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 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
 Intramedullary
Extramedullary

 Can cause
Similar symptoms
progressive
as a herniated
paraparesis
nucleus
 pulposus
Sensory loss
 Compress nerve roots leading to pain and
muscle weakness

59
Extramedullary Spinal Tumors

Meningioma
Neurofibroma 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
 Inchildren 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
 Surgicalresection
 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
 Communicating
Non-communicating
 Can come
be congenital
with increased cranial pressure
 Can be intrathoracic
Raised from tumor growth
pressure impairing
 venous
Trauma flow
(hemorrhage)

 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

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Hydrocephalus

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Hydrocephalus

78
Hydrocephalus Clinical Symptoms
 The cranial size is
enlarged
 Scalp veins distended
 Skin of scalp thin,
fragile and shiny
 Neck muscles
underdeveloped • In adults
 Severe cases • ALOC
 Orbital roofs are
• Ataxia
depressed
 Eyes displaced
• Incontinence
downwards • Decreased intellectual
capabilities 79
 Treatment of Hydrocephalus
 Placement of a shunt http://www.youtube.com/watch?v=0h7Xa-L
 Internal jugular, heart or snac
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
Ventricularjugular Shunt
treatment
http://www.youtube.com/watch?v=Qmym2
iFVNw8 80
 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  Non-
 communicating
The flow of CSF is free between ventricles &
subarachnoid space about cauda equina
 Obstruction

 Infants head is normal sizebetween

but thereventricles
is
and cauda equina
bulging of the frontal fontanelles
 Most common form
 Caused by poor absorption of CSF
of obstructive
hydrocephalus is
from abnormalities
between the 3rd
and 4th ventricles 83
 Multiple Sclerosis
 Chronicprogressive 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
 Poor
Difficulty
coordination
speaking clearly

 Tremors
Bladder dysfunction
 Muscle weakness
 Muscle impairment
 Double vision
 Loss of balance
 Nystagmus (rapid eye movement)

86
 HALLMARKS OF MS :

SPINAL
BRAIN CORD

DEMYELINATION AREAS 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  Corticosteroids (short
agents term)
 Limit the autoimmune
 Shortens the symptomatic
attack periods
 Delays progression of
disease
 Antiviral  Reduces frequency of
 Slows the progress of the attacks
disease

 Regular exercise
 Beta interferon  Reduces spasms and
 Immunomodulatory agents increases ROM
that reduce the severity of
the attacks
 Given subcutaneously 91
 Cerebrovascular Accident (CVA)
 Is an atherosclerotic disease affecting blood
supply to the brain
 3rd 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 CVA’s

 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

 MRIis 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  Glioma
System  MRI, CT
 Pathology Imaging Modalities of  Medulloblastoma
Choice Additive or Subtractive  MRI, CT
Pathology  Meningioma
 Hydrocephalus  CT, MRI
 CT, MRI, sonography in the neonate  Pituitary adenoma
 Meningitis  CT, MRI
 MRI  Craniopharyngioma
 Encephalitis  CT
 MRI  Acoustic neuroma
 Brain abscess  MRI
 CT, MRI  Spinal tumor
 Herniated nucleus pulposus  MRI, radiography, CT, myelography
 MRI, CT, myelography  Both Metastases from other sites
 Cervical spondylosis  MRI, radiography, CTSubtractive
 Radiography Subtractive
 Multiple sclerosis
 MRI
 CVA
 MRI, CT, sonography, PET

103