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Cns infections

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Cns infections

  1. 1. CNS INFECTIONS CT & MRI DR. MUHAMMAD BIN ZULFIQAR PGR 1
  2. 2. Types of Infections • • • • • • Bacterial Viral Spirochetal Fungal Protozoal Prions Disease
  3. 3. Routes of Spread • • • • • • Hematogenous Local(trans sinus, mastoid antrum ) During Birth Transplacental Iatrogenic Idiopathic
  4. 4. Presentation of infection •Pia or Subarachnoid space and/or dura or arachnoid •Empyema : epidural or subdural •Cerebritis :Intraparenchymal early stage of abcess formation •Intraparenchymal abcess •Ventriculitis
  5. 5. BACTARIAL infections • ORGANISMS INVOLVED • • • • Neonates:GROUP B Streptococcus,E.Coli,Listeria Young Children:Heamophilus,E.Coli,Nisseria meningitides Adults:Streptococcous pneumoniae,,N.Meningitidis Old age:S.pneumoniae,Listeria
  6. 6. Presentation of bacterial infections •Meningitis( Leptomeningitis, Pachymeningitis) •Empyema •Cerebritis • Brain abcess
  7. 7. Meningitis •Types •Predisposing Factors( Sinusitis, Chronic Pulmonary Infection, Tetrology of Fallot, Transposition of great vessels, other Cyanotic heart diseases) Imaging Features: a. Initially Normal on C.T. b. Convexity enhancement c. Basilar enhancement(more common on T.B.M.)
  8. 8. COMLICATIONS OF MENINGITIS 1. 2. 3. 4. 5. 6. Subdural effusion common in infants and children Empyema Parenchymal extension (Cerebritis ,Abcess formation) Hydrocephalous(communicating>non communicating Ventriculitis Venous infections secondary to thrombosis
  9. 9. Frontal sinusitis, empyema, and abscess formation in a patient with bacterial meningitis. This contrast-enhanced, axial T1weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiformshaped subdural empyema (arrows).
  10. 10. Chronic mastoiditis and epidural empyema in a patient with bacterial meningitis. This axial computed tomography scan shows sclerosis of the temporal bone (chronic mastoiditis), an adjacent epidural empyema with marked dural enhancement (arrow), and the absence of left mastoid air.
  11. 11. Brain Abcess 1. Children:(staphylococcal especially after trauma,Streptococcuc,Pneumococcus) 2. Adults:mixed aerobic and anaerobic flora 3. Immunosuppression:Toxoplasmosis,Cryptococcus,CandidiasisAspergi llosis,Nocardiosis,mucormycosis,T.B.Atypical Mycobacteria • MECHANISM 1. 2. • • • 3. Hematogenous Spread(I/V drug abuse,Sepsis) Direct Extension Sinusitis Otitis,Mastoiditis Open trauma(penetrating trauma,Surgery Idiopathic
  12. 12. Cerebral abscess. (A) Low-density lesion in occipital region with some mass effect. (B) After contrast medium, note thin ring of enhancement round the abscess with oedema anteriorly. (C) Multiple abscesses in frontoparietal area showing capsular enhancemenT after contrast medium (L34, W75).
  13. 13. Axial post-gadolinium T1WI showing ring-enhancing lesion with mass effect in a patient with pyogenic brain abscess.
  14. 14. Acute bacterial meningitis. This contrast-enhanced, axial T1weighted magnetic resonance image shows leptomeningeal enhancement (arrows).
  15. 15. Tuberculous Meningitis • • • • • • • Most common CNS manifestation of T.B. Followed by pulmonary T.B. Intraparenchymal Tuberculoma Basilar Meningeal involvement Cranial Nerve Palsies*(commonly Optic nerve) Hydrocephalous MRI IS MORE SENSITIVE
  16. 16. Imaging Features •Basilar Meningitis 1. Intense contrast enhancement of basilar Meninges(CT&MRI) 2. Pituitary and parasellar involvement 3. Pituitary or hypothalamic axis involvement 4. T2W hypo intense Meninges 5. Calcification occur late in disease • Tuberculoma(usually solitary, Nonspecific enhancing mass like lesion) • Miliary Form: Multiple tiny Intraparenchymal lesions
  17. 17. Enhanced CT of a patient with tuberculous meningitis showing perivascular inflammatory changes and temporal infarction due to vasculitis.
  18. 18. Viral Infections a) Specific Infections 1. RNA VIRUSES • • • • Enterovirus Arbovirus Rabies virus Paramyxovirus 2. DNA VIRUSES • • • • • Herpes Simplex Virus Cytomegalovirus Herpes zoster Papova virus Unidentified viruses(encephalitis lethargica,uveomeningoencephalitis,Behcets disease) b) Nonspecific Infections (measles,chickenpox,smallpox,rubella)
  19. 19. Herpes Simplex Virus Encephalitis HSV-1,oral herpes •Children and adults •Activation of latent virus in trigeminal ganglion •Altered mental status •Limbic system, frequently b/l but asymmetrical HSV-2 genital herpes •Neonatal torch infection •Acquired during parturition •Manifests several weeks after birth •Diffuse encephalitis(non focal)
  20. 20. IMAGING FEATURES •MRI is superior to CT •CT & MRI findings are normal initially •MRI detect changes even 2 to 3 days after disease •Distribution: limbic system , temporal lobe> cingulate gyrus,subfrontal region 1. Acute Stage • Decreased/restricted diffusion in affected areas Gyral oedema( T1W hypo intense/T2W hyperintense) No enhancement 2. Subacute stage Marked increase in edema bilateral asymmetrical involvement gyral enhancement Hemorrhage is common
  21. 21. HSE. T2 weighted MRI showing extensive area of increased signal in right temporal lobe and lesser involvement of the left.
  22. 22. Axial proton density– weighted image in a 62-yearold woman with confusion and herpes encephalitis shows T2 hyperintensity involving the right temporal lobe.
  23. 23. Axial nonenhanced T1weighted image shows cortical hyperintensity (arrows) consistent with petechial hemorrhage. In general, this is a common pathologic finding but less commonly depicted in herpes encephalitis.
  24. 24. Axial gadoliniumenhanced T1-weighted image reveals enhancement of the right anterior temporal lobe and parahippocampal gyrus. At the right anterior temporal tip is a hypo intense, crescentic region surrounded by enhancement consistent with a small epidural abscess.
  25. 25. Axial diffusion-weighted image reveals restricted diffusion in the left medial temporal lobe consistent with herpes encephalitis. This patient also had a positive result on polymerase chain reaction assay for herpes simplex virus, which is both sensitive and specific. In addition, the patient had periodic lateralized epileptiform discharges on electroencephalogram, which supports the diagnosis of herpes encephalitis.
  26. 26. hyperintensity in the left temporal lobe (arrows) in a distribution similar to the restricted diffusion abnormality seen in the previous image. This finding is typical for herpes encephalitis. In patients with HHV6 infection, one series noted that in addition to mesial temporal lobe abnormality, abnormal T2 hyperintensity has been seen in the insular and inferior frontal region, which may suggest the diagnosis. There are felt to be 2 typical imaging appearances: one seen in older adults involves T2 hyperintensity confined to the medial temporal lobe; in young adults, a more varied pattern has been described that includes foci of restricted diffusion with an otherwise normal magnetic resonance, diffuse cortical necrosis, or small focal regions of abnormal T2 hyperintensity.
  27. 27. Progressive multifocal leukoencephalopathy •Papova virus causative organism •Effect patients with compromised immunity •Multifocal demyelinating lesion spread in hemispheres often asymmetrically •MRI superior to CT •Spreading areas of low density seen on CT • Increased signals on T2W & less conspicuous reduced signals on T1W
  28. 28. Neurological outcomes of congenital CMV infection. Examples of computed tomography (A) and magnetic resonance imaging (B and C) of three infants with severe symptomatic congenital CMV infection with CNS involvement are shown. The classical pattern of injury described with congenital CMV infection involving the CNS is characterized by periventricular calcifications (panel A, arrow). Other consequences of fetal brain infection include abnormalities of neuronal migration, leading to polymicrogyria (panel B, arrows) and, in extreme cases, profound structural defects such as porencephalic cysts with associated schizencephaly (panel C, arrow).
  29. 29. Subacute sclerosing panencephalitis. Figure 1. MRI scans of the brain at the time of presentation in the neurology clinic (A and B) and 3 months later (C and D). Panels A and C are T1weighted images; B and D are T2weighted images. The initial MRI scan (A and B) reveals a focal abnormality in the subcortical white matter of the left frontal lobe, consisting of a hypointense signal on the T1-weighted image (arrow in A) and a hyperintense signal on the T2-weighted image (arrow in B). In the follow-up scan, the focal abnormality in the left frontal lobe is less obvious than previously (arrow in D), but advanced and diffuse cortical atrophy is present, signified by the ventriculomegaly and markedly enlarged sulci (arrowheads in C).
  30. 30. Axial FLAIR images of a patient with chronic HHV 6 encephalitis showing patchy signal hyperintensities in white matter and cortex.
  31. 31. AIDS •A neurotropic Virus •Can effect brain directly or can predispose to opportunistic infections •Common HIV –related infections include 1. HIV encephalopathy 2. Toxoplasmosis most common opportunistic infection of CNS 3. Cryptococcosis 4. Progressive multifocal leukoencephalopathy 5. TB 6. Syphilis 7. Varicella 8. CMV
  32. 32. HIV ENCEPHALOPATHY •Progressive sub acute sub cortical dementia secondary to HIV itself. •60% patients effected •IMAGING FEATURES •Atrophy most common finding •T2W bright WM lesion in frontal & occipital lobe and peri ventricular location(gliosis, demyelination) •No enhancement or mass effect of WM lesions •CT:diffuse white matter low attenuation •Most of AIDS findings seen are due to associated Viruses
  33. 33. Fungal Infections •Fungal infections of CNS only rarely seen in healthy people •Common Infections 1. Cryptococcosis 2. Aspergillosis 3. Candidiasis 4. Mucormycosis • Less common are Histoplasmosis,coccididomycosis,blastomycosis,cladosporiasis,nocardiosis,actino mycosis
  34. 34. Cryptococcal Infection •Meningitis spread along perivascular spaces •Multiple areas of enhanced signals on T2W images of basal ganglia and brainstem •Cystic lesions also seen
  35. 35. (A,B) Bilateral basal ganglia cryptococcomas, which have a slightly punctuate appearance on the T 2 -weighted images. On the T, coronal images, the lesions are slightly hypointense and those on the right exert some mass effect on the right frontal horn.
  36. 36. (C,D) Axial and coronal sections T2-weighted and T,-weighted show small enhancing abscess impinging on the right ventricle.
  37. 37. Aspergillosis •Hemorrhagic infarcts from vascular invasion •T2W isointense to hypointense masslike lesions
  38. 38. Coronal T1WI after gadolinium enhancement. Patient after bone marrow transplantation with aspergillus encephalitis. Ringenhancing lesion with perifocal edema and mass effect compressing the lateral ventricle.
  39. 39. Parasitic Infections •Protozoal: 1. 2. 3. 4. 5. Toxoplasmosis Amoebiasis Malaria Trypanosomiasis Chaga’s disease • Metazoal: • Tapeworm ( cestodiasis) • Fluke ( trematodes)
  40. 40. Toxoplasmosis •Toxoplasma Gondi •Two types(congenital & adult) •Commonly associated with AIDS •Congenital: •Gross degree of venticular dilatation •Extensive calcification of a) Basal ganglia b) Subcortical regions
  41. 41. (A,C) Congenital toxoplasmosis. Grossly dilated ventricles and calcified granulomas in atrophic cortex and basal ganglia
  42. 42. Adult toxoplasmosis Commonly associated with AIDS IMAGING FEATURES: •Single or multiple ring enhancing lesions with surrounding edema •Target appearance of lesion is common •Major consideration in D.D. is CNS LYPHOMA •Periventriclar location and subependymal spread favors lymphoma •Multiple lesions are suggestive of lyphoma
  43. 43. (A) Toxoplasmic encephalitis in a patient with AIDS.Multiple small abcesses with ring enhancement .A ring enhancing lesion proven to toxoplasmosis abcess is shown periphally in the left frontal lobe on the T2 axial(B) and T, coronal postcontrast imaging(C).the appearences are non-specific and there is a large amount of assosiated vasogenic edema.Multiple small enhancing nodules are present predominently at the grey-white matter junction in this T,axial image
  44. 44. (D) ASSOCIATED PERILESIONAL EDEMA IS CLEARLY SEEN ON T2 AXIAL IMAGE
  45. 45. (E)This patient was known to have Aids And have Multiple Toxoplasmosis abcesses
  46. 46. Cysticercosis •Taenia solium •Cysticercus cellulosae is larval stage •Acute stage shows small rounded low density lesion enhance with CM on CT •Chronic stage shows punctuate calcifications, obstructive hydrocephalous on CT •MRI demonstrate lesion well even in very early stage.
  47. 47. Human Coenurosis
  48. 48. Manifestation of palsy of left seventh cranial nerve in 10-year-old male patient with recent history of camping. Transverse T1weighted postcontrast MR image shows enhancement of left seventh cranial nerve (arrow). •Borrelia burgdorferi is the causative agent
  49. 49. Right facial numbness, pain, and paralysis in 42-year-old female patient. T1weighted postcontrast coronal MR images depict enhancement of (a) right trigeminal nerve (arrow)
  50. 50. NEUROSYPHILIS
  51. 51. Figure 2a. Sporadic CreutzfeldtJakob disease in a 65-year-old man 10 weeks after the onset of dementia, insomnia, and optical hallucinations and 4 weeks before the appearance of periodic synchronous discharges on the EEG. Diffusion-weighted image shows bilateral areas of abnormal high signal intensity in the cerebral cortex, caudate nuclei, putamen, and thalamus.
  52. 52. Diffusion-weighted image shows areas of abnormal high signal intensity in the left cerebral cortex and the bilateral caudate nuclei.
  53. 53. THANK YOU

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