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Brain Injury After Acute Carbon Monoxide Poisoning: Early and Late Complications

¹ Department of Radiology, Tri-Service General Hospital and, National Defense Medical Center, 325, Section 2, Cheng-Kung Rd., Neihu District, Taipei, Taiwan 114, Republic of China.
² Department of Undersea and Hyperbaric Medicine, TriService General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China.
³ Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan, Republic of China.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —31-year-old woman with carbon monoxide–induced acute hypoxic–ischemic change. Unenhanced CT scans of brain show diffuse hypodensity of gray matter involving cerebral cortex and basal ganglia. White matter is relatively spared.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —31-year-old woman with carbon monoxide–induced acute hypoxic–ischemic change. Unenhanced CT scans of brain show diffuse hypodensity of gray matter involving cerebral cortex and basal ganglia. White matter is relatively spared.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —29-year-old woman with carbon monoxide–induced focal cortical necrosis. Axial MR image obtained with FLAIR sequence (TR/TE, 9,000/110; inversion time, 2,500 milliseconds) on day of carbon monoxide exposure shows bilateral cortical hyperintensity involving temporal lobes, including medial temporal lobes with predominance on right side.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —29-year-old woman with carbon monoxide–induced focal cortical necrosis. Diffusion-weighted MR image (5,000/120; b = 0 and 1,000 s/mm2) (B) and corresponding apparent diffusion coefficient map (C) show restricted water diffusion, indicating cytotoxic edema.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —29-year-old woman with carbon monoxide–induced focal cortical necrosis. Diffusion-weighted MR image (5,000/120; b = 0 and 1,000 s/mm2) (B) and corresponding apparent diffusion coefficient map (C) show restricted water diffusion, indicating cytotoxic edema.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —29-year-old woman with carbon monoxide–induced focal cortical necrosis. Two-dimensional time-of-flight MR angiogram shows no evidence of major arterial occlusion.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —29-year-old woman with carbon monoxide–induced focal cortical necrosis. T1-weighted image (600/14) obtained 2 months after carbon monoxide exposure shows cortical necrosis with brain tissue loss and gyriform hyperintensity (lamellar necrosis) over right temporal lobe.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —29-year-old woman with acute carbon monoxide poisoning. Unenhanced (A) and contrast-enhanced (B) T1-weighted images show hypointensity with bilateral patchy enhancement in globi pallidi (arrows, B).

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —29-year-old woman with acute carbon monoxide poisoning. Unenhanced (A) and contrast-enhanced (B) T1-weighted images show hypointensity with bilateral patchy enhancement in globi pallidi (arrows, B).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —29-year-old woman with acute carbon monoxide poisoning. T2-weighted images obtained 1 day (C), 2 weeks (D), and 2 months (E) after poisoning show gradual collapse of globi pallidi.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —29-year-old woman with acute carbon monoxide poisoning. T2-weighted images obtained 1 day (C), 2 weeks (D), and 2 months (E) after poisoning show gradual collapse of globi pallidi.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E —29-year-old woman with acute carbon monoxide poisoning. T2-weighted images obtained 1 day (C), 2 weeks (D), and 2 months (E) after poisoning show gradual collapse of globi pallidi.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —30-year-old woman with carbon monoxide–induced cerebellar lesions. FLAIR MR image obtained on day after carbon monoxide exposure shows bilateral areas of increased signal intensity (arrows) in cerebellar hemispheres.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —30-year-old woman with carbon monoxide–induced cerebellar lesions. FLAIR MR image obtained 6 months after carbon monoxide exposure shows area of abnormal signal intensity has disappeared.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —30-year-old woman with carbon monoxide–induced brainstem lesion. Axial unenhanced (A) and contrast-enhanced (B) T1-weighted images obtained on day after carbon monoxide exposure show bilateral areas (arrows, B) of mild enhancement over cerebral peduncles of midbrain.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —30-year-old woman with carbon monoxide–induced brainstem lesion. Axial unenhanced (A) and contrast-enhanced (B) T1-weighted images obtained on day after carbon monoxide exposure show bilateral areas (arrows, B) of mild enhancement over cerebral peduncles of midbrain.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —30-year-old woman with carbon monoxide–induced brainstem lesion. Unenhanced T1-weighted image obtained 6 months after carbon monoxide exposure shows hyperintense foci over previous lesion sites, possibly owing to necrosis with dystrophic microcalcification.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —30-year-old woman with carbon monoxide–induced brainstem lesion. MR image obtained with gray matter suppression sequence (TR/TE, 2,000/30; inversion time, 420 milliseconds) 6 months after carbon monoxide exposure shows bilateral blurring of pars compacta (arrows) of substantia nigra. Marked Parkinson's disease–like symptoms did not develop.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —40-year-old man with carbon monoxide intoxication. T2-weighted images obtained 1 month after carbon monoxide exposure show bilateral hyperintensity of cerebral white matter.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —40-year-old man with carbon monoxide intoxication. T2-weighted images obtained 1 month after carbon monoxide exposure show bilateral hyperintensity of cerebral white matter.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —40-year-old man with carbon monoxide intoxication. T2-weighted images obtained 2 years after carbon monoxide exposure show generalized brain atrophy with enlarged CSF spaces.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —40-year-old man with carbon monoxide intoxication. T2-weighted images obtained 2 years after carbon monoxide exposure show generalized brain atrophy with enlarged CSF spaces.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —35-year-old woman with carbon monoxide–induced delayed neuropsychiatric syndrome. Axial FLAIR MR images obtained 6 days (A), 2 months (B), 3 months (C), and 6 months (D) after insult show abnormal area of high signal intensity in bilateral periventricular white matter, which may be due to demyelination, not evident early (A) but prominent at 2 months (B) with gradual attenuation.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —35-year-old woman with carbon monoxide–induced delayed neuropsychiatric syndrome. Axial FLAIR MR images obtained 6 days (A), 2 months (B), 3 months (C), and 6 months (D) after insult show abnormal area of high signal intensity in bilateral periventricular white matter, which may be due to demyelination, not evident early (A) but prominent at 2 months (B) with gradual attenuation.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —35-year-old woman with carbon monoxide–induced delayed neuropsychiatric syndrome. Axial FLAIR MR images obtained 6 days (A), 2 months (B), 3 months (C), and 6 months (D) after insult show abnormal area of high signal intensity in bilateral periventricular white matter, which may be due to demyelination, not evident early (A) but prominent at 2 months (B) with gradual attenuation.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —35-year-old woman with carbon monoxide–induced delayed neuropsychiatric syndrome. Axial FLAIR MR images obtained 6 days (A), 2 months (B), 3 months (C), and 6 months (D) after insult show abnormal area of high signal intensity in bilateral periventricular white matter, which may be due to demyelination, not evident early (A) but prominent at 2 months (B) with gradual attenuation.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —31-year-old man with carbon monoxide inhalation. Axial FLAIR MR images obtained 3 days (A) and 1 month (B) after carbon monoxide exposure show diffuse and progressive white matter hyperintensity that extends to subcortical white matter.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —31-year-old man with carbon monoxide inhalation. Axial FLAIR MR images obtained 3 days (A) and 1 month (B) after carbon monoxide exposure show diffuse and progressive white matter hyperintensity that extends to subcortical white matter.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —35-year-old woman who attempted suicide by burning charcoal. Diffusion-weighted MR image (A) and corresponding apparent diffusion coefficient map (B) obtained 2 months after carbon monoxide exposure show restricted water diffusion over bilateral centrum semiovale, indicating delayed cytotoxic edema.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —35-year-old woman who attempted suicide by burning charcoal. Diffusion-weighted MR image (A) and corresponding apparent diffusion coefficient map (B) obtained 2 months after carbon monoxide exposure show restricted water diffusion over bilateral centrum semiovale, indicating delayed cytotoxic edema.

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