Neuroradiology for the Hospitalist What You Really Need to Know - PDF document

10/16/2018 Neuroradiology for the Hospitalist What You Really Need to Know Christopher P. Hess, M.D., Ph.D. S. Andrew Josephson, M.D. Disclosures C.P.H. – Editorial Board, Radiology, AJNR S.A.J. – Editor, JAMA Neurology 1

10/16/2018 Goals for This Talk 1. Use cases to discuss best practice for use of imaging 2. Identify neurologic emergencies on CT 3. Recognize implications of imaging on management 4. Provide update on imaging safety – devices, contrast Key Questions When does your patient need imaging? Can you recognize key emergencies on CT? How should the results of imaging guide management? 2

10/16/2018 3

10/16/2018 HEAD CT: “NEURO’S CHEST X-RAY” • Hemorrhage • Herniation 5 H’s • Hydrocephalus • Hypodensity • Huge clot 4

10/16/2018 HEAD CT INTERPRETATION 101 • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? 5

10/16/2018 • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? 6

10/16/2018 • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? Can be subtle – w hich hemisphere is abnormal here? • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? 7

10/16/2018 • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? Normal – distinct gray-w hite boundary • Is there blood present ? • Is the midline in the middle ? • Does the brain look symmetric ? • Are the ventricles and cisterns ok ? • Can you see gray and w hite matter ? Abnormal (anoxia) – loss of gray-w hite boundary 8

10/16/2018 32 year old w ith altered mental status progressing to non-responsiveness, took GHB during rave 9

10/16/2018 A 81 year old inpatient w ith longstanding severe hypertension is hospitalized for treatment of a diabetic foot ulcer. Two days into his hospitalization he develops sudden left sided w eakness. “Classic” Hypertensive Hemorrhage Locations • Basal ganglia • Thalamus • Pons • Cerebellum • (Lobar) 10

10/16/2018 Same history, different patient: CTA Same history, different patient: 11

10/16/2018 Same history, different patient: MRI 12

10/16/2018 Different patient w ith hemorrhage A 73 year old inpatient is POD#2 from an uncomplicated total hip arthroplasty. 3 hours after last being seen normal, she is found to have difficulty speaking and right hemiparesis. 13

10/16/2018 Next Step? 14

10/16/2018 Likely outcome pre 1995: 15

10/16/2018 64 year old woman w ith vertigo, ataxia 16

10/16/2018 CT Has Low Sensitivity for Cerebellar and Brainstem Ischemia Go w ith Diffusion-Weighted Imaging (DWI) A 32 year old inpatient has been admitted for evaluation of 3 days of fever and altered mental status. He has no know n comorbidities. 17

10/16/2018 Stroke? Next Step? 18

10/16/2018 HSV-1 Meningoencephalitis • How to make the diagnosis? - CSF lymphocytic pleocytosis (can be normal) - EEG (can be normal) - MRI (can be normal) - CSF HSV PCR • If suspected, start IV acyclovir 10-15mg/kg q 8 hours 57 year old breast cancer patient, inpatient admission for headaches, difficulty concentrating 19

10/16/2018 Next Step? But w ait! The patient has an ICD … 20

10/16/2018 MRI Safety - Devices UCSF Practice Parameters 1. Pacemakers, ICDs, DBS - can be done safely using SOP 2. Coronary stents - all ok at 3T if > 6 w eeks 3. Epicardial pacer w ires - must be cut or removed 4. Aneurysm clips – usually safe (UCSF pre-1995) 5. Drug infusion pumps - usually safe follow ing SOP https://radiology.ucsf.edu/patient-care/patient-safety/ Should w e give contrast? 21

10/16/2018 When is MRI Contrast Helpful? • Leptomeningeal disease • Metastatic disease • Infection or inflammatory disease • Lesion characterization • Certain structures, examples - pituitary gland, cavernous sinuses, internal auditory canals When is MRI Contrast NOT Helpful? • Routine stroke MRI • AMS w orkup • MOST inpatient indications 22

10/16/2018 Risks of Gadolinium Contrast 1. Allergic reactions - 0.004 - 0.7% of patients (anaphylaxis rate 0.001 - 0.01% of patients) 2. Nephrogenic systemic fibrosis (NSF) 3. Brain stain 23

10/16/2018 MRI Safety - Gadolinium Nephrogenic Systemic Fibrosis MRI Safety - Gadolinium Gadolinium Deposition –“Brain Stain” 24

10/16/2018 Management question for a subtle physical exam finding w hile you are moonlighting in the ER one day SCOUT FROM CT SCAN 25

10/16/2018 MCA ACA Knife tip What is the Best Next Step? 1. Slow ly pull out the knife 2. Craniotomy to remove the knife 3. CT study 4. MR study 5. Break the handle off the blade and leave it 26

10/16/2018 74 year-old man, suddenly unresponsive w hile on the floor getting IV antibiotics for CAP. Code called. 27

10/16/2018 DWI Predicts Outcome in Basilar Thrombosis 28

10/16/2018 Basilar Artery Thrombosis • Carries a high mortality • Common from cardioembolic disease or vertebral artery dissection (in young) • Embolectomy successful out to 12-24 hours • CTA can identify this and other posterior circulation occlusions/stenoses (VBI) • Clues on exam - vertigo or coma w ith any cranial nerve abnormalities 64 year old woman w ith acute onset of WHOL 29

10/16/2018 30

10/16/2018 Subtle SAH – Look in Dependent Areas 31

10/16/2018 Sensitivity of Unenhanced CT • STANDARD OF CARE IS 95-99% sensitive first 24 hrs LP WHEN CT • 50% after 1 w eek NEGATIVE • 30% after 2 w eeks • NPV 98-100% 0% after 3 w eeks 47 year old man w ith severe headaches for 2 w eeks 32

10/16/2018 CTA negative for aneurysm… High Density Subarachnoid Blood Pus Tumor Granulomas Contrast Postcon CT 33

10/16/2018 36 year-old woman admitted w ith intractable headache CEC 34

10/16/2018 (Empty) Delta Sign Superior Sagittal Sinus Thrombosis Postcon Noncon Confirm w ith MRI or CTV T2 T1 35

10/16/2018 Venous Sinus Thrombosis - Treatment • Control elevated ICP • Control seizures • Anticoagulation • Treat primary cause: OCPs, hypercoag states • Outcomes Mortality ~ 30% - Residual deficits in ~ 30% - Venous Sinus Thrombosis - Outcomes • More favorable prognosis than w ith arterial stroke • Younger population in general • Many deficits due to edema rather than infarction • DWI lesions not necessarily irreversible • Typically reimage in 3-6 months to assess extent of injury, venous recanalization 36

10/16/2018 Deep Venous Thrombosis Summary 1. Remember the 5 H’s –look outside the brain on CT 2. CT is the chest x-ray of neuroradiology 3. Few er barriers now to MRI than in the past 4. Think about next steps based on CT results 37

10/16/2018 THANKS christopher.hess@ ucsf.edu andrew.josephson@ ucsf.edu 38