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Nontraumatic Emergent Neuroradiology: Review and Self-Assessment Module

¹ Department of Radiology, Division of Neuroradiology, University of Washington, 1959 NE Pacific St., NW 011, Box 357115, Seattle, WA 98195-7115.
² Department of Radiology, Harborview Medical Center, Seattle, WA.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —32-year-old man with headache and general fatigue who was diagnosed with viral syndrome and discharged but returned with severe headache and confusion. Unenhanced CT (A) and CT angiography (B) of head were performed. Unenhanced CT shows large right frontal intraparenchymal hematoma and surrounding edema (arrow, A), likely representing subacute intracranial hematoma. CT angiography does not reveal any cerebral aneurysms, arteriovenous malformation, or enhancing focus as possible cause of hematoma.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —32-year-old man with headache and general fatigue who was diagnosed with viral syndrome and discharged but returned with severe headache and confusion. Unenhanced CT (A) and CT angiography (B) of head were performed. Unenhanced CT shows large right frontal intraparenchymal hematoma and surrounding edema (arrow, A), likely representing subacute intracranial hematoma. CT angiography does not reveal any cerebral aneurysms, arteriovenous malformation, or enhancing focus as possible cause of hematoma.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —32-year-old man with headache and general fatigue who was diagnosed with viral syndrome and discharged but returned with severe headache and confusion. Cerebral angiography shows irregularity of small- to medium-sized vessels (arrows, D) and beaded appearance, consistent with vasculitis. Patient admitted that he smokes marijuana almost daily and has long history of amphetamine use.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —32-year-old man with headache and general fatigue who was diagnosed with viral syndrome and discharged but returned with severe headache and confusion. Cerebral angiography shows irregularity of small- to medium-sized vessels (arrows, D) and beaded appearance, consistent with vasculitis. Patient admitted that he smokes marijuana almost daily and has long history of amphetamine use.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. Unenhanced CT scan of head obtained at outside hospital shows focal area of low attenuation in left temporal lobe and mild regional mass effect. Ventricles are normal in size with no shift of midline structures. No parenchymal hemorrhage is evident.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. Contrast-enhanced image from other hospital shows empty delta sign (arrows).

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. Brain MR images, including sagittal T1-weighted (C), diffusion-weighted (D), and apparent diffusion coefficient (ADC) map (E) images obtained at outside hospital. T1-weighted image shows hyperintense clot along superior sagittal sinus (arrows), causing concern for superior sagittal sinus thrombosis. Diffusion-weighted images show no areas of restricted diffusion or ADC map abnormality.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. Brain MR images, including sagittal T1-weighted (C), diffusion-weighted (D), and apparent diffusion coefficient (ADC) map (E) images obtained at outside hospital. T1-weighted image shows hyperintense clot along superior sagittal sinus (arrows), causing concern for superior sagittal sinus thrombosis. Diffusion-weighted images show no areas of restricted diffusion or ADC map abnormality.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. Brain MR images, including sagittal T1-weighted (C), diffusion-weighted (D), and apparent diffusion coefficient (ADC) map (E) images obtained at outside hospital. T1-weighted image shows hyperintense clot along superior sagittal sinus (arrows), causing concern for superior sagittal sinus thrombosis. Diffusion-weighted images show no areas of restricted diffusion or ADC map abnormality.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2F —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. CT scans of head obtained immediately after admission to our hospital show marked worsening of cerebral edema and diffuse effacement of cortical sulci and basilar cistern. In addition, new focus of venous infarction and parenchymal hemorrhage (arrow, F) is present in left frontal lobe.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2G —19-year-old woman who presented to another hospital with severe headache, nausea, vomiting, and photophobia. CT scans of head obtained immediately after admission to our hospital show marked worsening of cerebral edema and diffuse effacement of cortical sulci and basilar cistern. In addition, new focus of venous infarction and parenchymal hemorrhage (arrow, F) is present in left frontal lobe.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —48-year-old woman with "the worst headache of my life" and declining level of consciousness. Unenhanced CT scans show diffuse subarachnoid hemorrhage in basilar cistern and sylvian fissures bilaterally and along anterior falx, associated with intraventricular hemorrhage. Temporal horns of lateral ventricle are mildly dilated, suggestive of developing hydrocephalus. Focal hematoma (arrow) in medial frontal region is also evident.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —48-year-old woman with "the worst headache of my life" and declining level of consciousness. Unenhanced CT scans show diffuse subarachnoid hemorrhage in basilar cistern and sylvian fissures bilaterally and along anterior falx, associated with intraventricular hemorrhage. Temporal horns of lateral ventricle are mildly dilated, suggestive of developing hydrocephalus. Focal hematoma (arrow) in medial frontal region is also evident.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —48-year-old woman with "the worst headache of my life" and declining level of consciousness. Thin-slice maximum-intensity-projection (C) and 3D volume-rendering (D) images show lobulated saccular aneurysm (arrow) arising from anterior communicating artery and measuring approximately 5 mm. Proximal A2 segments(arrowhead, D) of anterior cerebral arteries are displaced laterally, likely due to surrounding aneurysm.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —48-year-old woman with "the worst headache of my life" and declining level of consciousness. Thin-slice maximum-intensity-projection (C) and 3D volume-rendering (D) images show lobulated saccular aneurysm (arrow) arising from anterior communicating artery and measuring approximately 5 mm. Proximal A2 segments(arrowhead, D) of anterior cerebral arteries are displaced laterally, likely due to surrounding aneurysm.

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E —48-year-old woman with "the worst headache of my life" and declining level of consciousness. Three-dimensional rotational angiography shows detailed anatomy and morphology of anterior communicating aneurysm, adjacent ophthalmic artery, and perforating arteries (arrow), which are not easily visualized on CT angiography.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. Unenhanced CT scans show loss of gray matter–white matter differentiation (arrowheads) in left insular cortex and temporal lobe. Left middle cerebral artery (MCA) is hyperdense compared with basilar artery (arrow, A).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. Unenhanced CT scans show loss of gray matter–white matter differentiation (arrowheads) in left insular cortex and temporal lobe. Left middle cerebral artery (MCA) is hyperdense compared with basilar artery (arrow, A).

View larger version (208K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. Left internal carotid artery injection image shows presence of clot (arrow) in internal carotid bifurcation and no flow visible in anterior and middle cerebral arteries.

View larger version (209K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. Unsubtracted angiography shows microcatheter placed proximal to clot (arrow) before retrieval device was advanced.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. Subsequent angiography shows persistent occlusion of MCA branches (arrow). Intraarterial tissue plasminogen activator (tPA) was infused through left MCA.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4F —65-year-old woman 4 hours after onset of right-sided weakness and dysarthria who underwent cerebral angiography for potential endovascular intervention. After infusion, tPA angiography shows opening of anterior division of left MCA and occlusion (arrow) of posterior division of left MCA.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. Unenhanced CT scans of head shows vague area of low attenuation in right cerebellar hemisphere and mild mass effect on right aspect of fourth ventricle (arrow, A). No hemorrhage, hydrocephalus, or midline shift is present.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. Unenhanced CT scans of head shows vague area of low attenuation in right cerebellar hemisphere and mild mass effect on right aspect of fourth ventricle (arrow, A). No hemorrhage, hydrocephalus, or midline shift is present.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. MR images of brain obtained 2 days after A and B. FLAIR images (C and D) show numerous foci of hyperintensity throughout cerebral and cerebellar hemispheres, predominantly at corticomedullary junction. Some lesions are seen in basal ganglia as well as thalamus. Extent of disease is more than expected from CT, indicating rapid progression of disease process. These numerous foci are markedly hyperintense on diffusion-weighted images (E and F). Contrast-enhanced T1-weighted image (G) shows no area of abnormal enhancement on any lesions.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. MR images of brain obtained 2 days after A and B. FLAIR images (C and D) show numerous foci of hyperintensity throughout cerebral and cerebellar hemispheres, predominantly at corticomedullary junction. Some lesions are seen in basal ganglia as well as thalamus. Extent of disease is more than expected from CT, indicating rapid progression of disease process. These numerous foci are markedly hyperintense on diffusion-weighted images (E and F). Contrast-enhanced T1-weighted image (G) shows no area of abnormal enhancement on any lesions.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5E —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. MR images of brain obtained 2 days after A and B. FLAIR images (C and D) show numerous foci of hyperintensity throughout cerebral and cerebellar hemispheres, predominantly at corticomedullary junction. Some lesions are seen in basal ganglia as well as thalamus. Extent of disease is more than expected from CT, indicating rapid progression of disease process. These numerous foci are markedly hyperintense on diffusion-weighted images (E and F). Contrast-enhanced T1-weighted image (G) shows no area of abnormal enhancement on any lesions.

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5F —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. MR images of brain obtained 2 days after A and B. FLAIR images (C and D) show numerous foci of hyperintensity throughout cerebral and cerebellar hemispheres, predominantly at corticomedullary junction. Some lesions are seen in basal ganglia as well as thalamus. Extent of disease is more than expected from CT, indicating rapid progression of disease process. These numerous foci are markedly hyperintense on diffusion-weighted images (E and F). Contrast-enhanced T1-weighted image (G) shows no area of abnormal enhancement on any lesions.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5G —38-year-old woman with severe headache, nausea, and vomiting. Patient had history of heart transplantation. MR images of brain obtained 2 days after A and B. FLAIR images (C and D) show numerous foci of hyperintensity throughout cerebral and cerebellar hemispheres, predominantly at corticomedullary junction. Some lesions are seen in basal ganglia as well as thalamus. Extent of disease is more than expected from CT, indicating rapid progression of disease process. These numerous foci are markedly hyperintense on diffusion-weighted images (E and F). Contrast-enhanced T1-weighted image (G) shows no area of abnormal enhancement on any lesions.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —27-year-old woman with 2-week history of nausea and vomiting after recent cholecystectomy. Patient presented with abdominal pain and nausea. FLAIR images show bilateral symmetric hyperintensity involving mamillary bodies, medial thalami along third ventricle, and periaqueductal gray matter (arrows, A–C). Diffusion-weighted image (D) also shows area of hyperintensity in medial thalami.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —27-year-old woman with 2-week history of nausea and vomiting after recent cholecystectomy. Patient presented with abdominal pain and nausea. FLAIR images show bilateral symmetric hyperintensity involving mamillary bodies, medial thalami along third ventricle, and periaqueductal gray matter (arrows, A–C). Diffusion-weighted image (D) also shows area of hyperintensity in medial thalami.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —27-year-old woman with 2-week history of nausea and vomiting after recent cholecystectomy. Patient presented with abdominal pain and nausea. FLAIR images show bilateral symmetric hyperintensity involving mamillary bodies, medial thalami along third ventricle, and periaqueductal gray matter (arrows, A–C). Diffusion-weighted image (D) also shows area of hyperintensity in medial thalami.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —27-year-old woman with 2-week history of nausea and vomiting after recent cholecystectomy. Patient presented with abdominal pain and nausea. FLAIR images show bilateral symmetric hyperintensity involving mamillary bodies, medial thalami along third ventricle, and periaqueductal gray matter (arrows, A–C). Diffusion-weighted image (D) also shows area of hyperintensity in medial thalami.

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