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CT and MR Imaging of Nontraumatic Neurologic Emergencies

¹ Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

View larger version (131K): [in a new window]   Arthur W. Goodspeed, 4th President, 1903-1904

View larger version (131K): [in a new window]   James B. Bulitt, 5th President, 1904-1905

View larger version (108K): [in a new window]   Fig. 1A. —Hemorrhagic venous infarction in 41-year-old woman with dural sinus thrombosis. Unenhanced axial CT scan shows hyperdense appearance of superior sagittal sinus (arrowheads) and straight sinus (solid arrow), consistent with thrombosis. Note hemorrhagic lesion in right frontal lobe (open arrow). Subcortical location and hemorrhagic nature of lesion are typical of venous infarction.

View larger version (123K): [in a new window]   Fig. 1B. —Hemorrhagic venous infarction in 41-year-old woman with dural sinus thrombosis. Contrast-enhanced coronal T1-weighted MR image obtained same day as A shows replacement of flow voids of superior sagittal sinus (straight arrow) and straight sinus (curved arrow) by thrombus that is isointense with gray matter. Note mild rim enhancement of thrombus.

View larger version (122K): [in a new window]   Fig. 1C. —Hemorrhagic venous infarction in 41-year-old woman with dural sinus thrombosis. Axial T2-weighted MR image shows more extensive region of hemorrhage (arrows) than that seen in A. Note hypointense signal intensity of thrombus in superior sagittal sinus (arrowheads), which simulates flow void.

View larger version (131K): [in a new window]   Fig. 2A. —Dural sinus thrombosis in 38-year-old woman with headache. Unenhanced axial CT scan shows hyperdense appearance of superior sagittal sinus (arrows), consistent with thrombosis.

View larger version (78K): [in a new window]   Fig. 2B. —Dural sinus thrombosis in 38-year-old woman with headache. CT venogram, lateral view, shows opacification of anterior portion of superior sagittal sinus (curved arrow), inferior sagittal sinus (arrowheads), and internal cerebral veins (open arrow). Posterior portion of superior sagittal sinus (solid arrows) is not opacified because of thrombosis.

View larger version (125K): [in a new window]   Fig. 3A. —Transverse sinus thrombosis in 8-month-old female infant who had recently undergone resection of suprasellar mass. Unenhanced axial CT scan shows hyperdense appearance of left transverse sinus (arrowhead), consistent with thrombosis. Note pneumocephalus (arrows) resulting from recent surgery.

View larger version (123K): [in a new window]   Fig. 3B. —Transverse sinus thrombosis in 8-month-old female infant who had recently undergone resection of suprasellar mass. Unenhanced axial T1-weighted MR image shows abnormal signal (arrows) replacing expected flow void in left transverse sinus.

View larger version (163K): [in a new window]   Fig. 3C. —Transverse sinus thrombosis in 8-month-old female infant who had recently undergone resection of suprasellar mass. Collapsed image from three-dimensional time-of-flight MR venogram (in which all data are viewed looking caudad) shows normal flow in superior sagittal sinus (solid straight arrow) and right transverse sinus (curved arrow) but absence of flow in expected location of left transverse sinus (open arrows).

View larger version (132K): [in a new window]   Fig. 4A. —Posterior white matter abnormalities caused by reversible posterior leukoencephalopathy syndrome in 38-year-old man with severe hypertension, headache, vomiting, and seizures. Unenhanced axial CT scan shows bilateral hypodense white matter lesions (arrowheads) that are more marked in posterior brain regions.

View larger version (148K): [in a new window]   Fig. 4B. —Posterior white matter abnormalities caused by reversible posterior leukoencephalopathy syndrome in 38-year-old man with severe hypertension, headache, vomiting, and seizures. Axial T2-weighted MR image obtained 1 day after A shows regions of hyperintense signal intensity (arrows) in abnormal regions seen in A. Lesions terminate at gray—white matter junction, consistent with vasogenic edema. After control of hypertension, central nervous system symptoms resolved.

View larger version (79K): [in a new window]   Fig. 5A. —Bilateral internal carotid artery dissections in 44-year-old man who developed right-sided neck pain and right Horner's syndrome a few days after downhill skiing. He had no history of direct trauma. Catheter angiogram of right common carotid artery, lateral view, shows long segment of luminal narrowing in high cervical segment (arrows), consistent with dissection, and extending up to level of skull base.

View larger version (166K): [in a new window]   Fig. 5B. —Bilateral internal carotid artery dissections in 44-year-old man who developed right-sided neck pain and right Horner's syndrome a few days after downhill skiing. He had no history of direct trauma. Unenhanced axial T1-weighted MR image shows narrowing of flow void of right internal artery with eccentric hyperintense intramural hematoma that expands outer diameter of artery (straight arrow). Note normal caliber of left internal carotid artery (curved arrow).

View larger version (87K): [in a new window]   Fig. 5C. —Bilateral internal carotid artery dissections in 44-year-old man who developed right-sided neck pain and right Horner's syndrome a few days after downhill skiing. He had no history of direct trauma. Catheter angiogram of left common carotid artery, lateral view, shows pseudoaneurysm (arrow) resulting from dissection in cervical segment. Because dissection did not extend to skull base, it is not seen in B.

View larger version (128K): [in a new window]   Fig. 5D. —Bilateral internal carotid artery dissections in 44-year-old man who developed right-sided neck pain and right Horner's syndrome a few days after downhill skiing. He had no history of direct trauma. Two-dimensional time-of-flight MR angiogram shows, adjacent to left internal carotid artery, small focal region (straight arrow) of abnormal flow, corresponding to pseudoaneurysm seen in C. Note narrowing of right internal carotid artery (curved arrow) corresponding to dissection in A.

View larger version (82K): [in a new window]   Fig. 6A. —Right internal carotid artery dissection in 42-year-old woman with right-sided neck pain and oculosympathetic paresis (Horner's syndrome). Source image from CT angiogram shows marked narrowing of right internal carotid artery (curved arrow) compared with left internal carotid artery (straight arrow) because of dissection. Note that soft tissue immediately surrounding artery does not differ from normal muscle (unlike appearance seen on MR image in Figure 5A, 5B, 5C, 5D).

View larger version (55K): [in a new window]   Fig. 6B. —Right internal carotid artery dissection in 42-year-old woman with right-sided neck pain and oculosympathetic paresis (Horner's syndrome). Three-dimensional reconstruction from CT angiogram of right internal carotid artery shows long segment of arterial narrowing (arrows) beginning distal to carotid bifurcation. Note more focal segment of narrowing (arrowhead) in mid portion of stenosis.

View larger version (136K): [in a new window]   Fig. 7A. —Pseudoaneurysm formation caused by vertebral artery dissection in 50-year-old woman with headache. Unenhanced axial T1-weighted MR image shows mass (arrow) adjacent to medulla in expected location of right vertebral artery.

View larger version (147K): [in a new window]   Fig. 7B. —Pseudoaneurysm formation caused by vertebral artery dissection in 50-year-old woman with headache. Source image from three-dimensional time-of-flight MR angiogram shows flow (arrow) consistent with right vertebral artery pseudoaneurysm within mass shown in A. Absence of flow void in lesion is probably caused by slow flow in pseudoaneurysm.

View larger version (152K): [in a new window]   Fig. 7C. —Pseudoaneurysm formation caused by vertebral artery dissection in 50-year-old woman with headache. Catheter angiogram of right vertebral artery, lateral view, shows abnormal dilatation of artery (arrow) consistent with pseudoaneurysm.

View larger version (127K): [in a new window]   Fig. 8A. —61-year-old woman with 6-day history of encephalopathy caused by herpes simplex type 1 encephalitis. Unenhanced axial CT scan shows right temporal lobe hypodensity and swelling (solid arrow), narrowing of right sylvian fissure, and hypodensity in right insula (open arrows).

View larger version (136K): [in a new window]   Fig. 8B. —61-year-old woman with 6-day history of encephalopathy caused by herpes simplex type 1 encephalitis. Contrast-enhanced axial T1-weighted MR image obtained 2 days after A shows mild gyriform contrast enhancement of right temporal lobe (arrowheads). Note absence of right temporal lobe sulci (arrows) caused by swelling, compared with left temporal lobe.

View larger version (130K): [in a new window]   Fig. 8C. —61-year-old woman with 6-day history of encephalopathy caused by herpes simplex type 1 encephalitis. Axial T2-weighted MR image shows increased signal intensity in right temporal lobe (open arrows) and inferior frontal region (solid arrow).

View larger version (132K): [in a new window]   Fig. 8D. —61-year-old woman with 6-day history of encephalopathy caused by herpes simplex type 1 encephalitis. Axial T2-weighted MR image shows increased signal intensity in right insula (open arrows) and temporal lobe, anterior aspect of cingulate gyrus and subcallosal region (curved arrow), and left insula (solid straight arrow). Note sparing of basal ganglia.

View larger version (148K): [in a new window]   Fig. 9A. —50-year-old man with 4-day history of confusion and somnolence caused by herpes simplex type 1 encephalitis. Axial T2-weighted MR image shows markedly increased signal in left temporal lobe and mildly increased signal intensity in right medial temporal lobe (arrow). Findings of diffuse bilateral temporal lobe involvement would not be expected in tumor or infarction.

View larger version (145K): [in a new window]   Fig. 9B. —50-year-old man with 4-day history of confusion and somnolence caused by herpes simplex type 1 encephalitis. Coronal contrast-enhanced T1-weighted MR image shows thick contrast enhancement in medial left temporal lobe (straight arrows) and smaller region of contrast enhancement in right hippocampus (curved arrow). Compare thickness of contrast enhancement in left temporal lobe with thin gyriform enhancement seen in Figure 8A, 8B, 8C, 8D.

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