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

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

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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

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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

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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?

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  • Hemorrhage
  • Herniation
  • Hydrocephalus
  • Hypodensity
  • Huge clot

HEAD CT: “NEURO’S CHEST X-RAY”

5 H’s

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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 ?
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  • 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 ?
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  • 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 ?

Can be subtle – w hich hemisphere is abnormal here?

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  • 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

  • f gray-w hite boundary
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32 year old w ith altered mental status progressing to non-responsiveness, took GHB during rave

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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)
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CTA

Same history, different patient: Same history, different patient:

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Same history, different patient:

MRI

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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.

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Next Step?

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Likely outcome pre 1995:

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64 year old woman w ith vertigo, ataxia

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Go w ith Diffusion-Weighted Imaging (DWI)

CT Has Low Sensitivity for Cerebellar and Brainstem Ischemia

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.
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Stroke? Next Step?

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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

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Next Step?

But w ait! The patient has an ICD …

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UCSF Practice Parameters

MRI Safety - Devices

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?

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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
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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

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Nephrogenic Systemic Fibrosis

MRI Safety - Gadolinium

Gadolinium Deposition –“Brain Stain”

MRI Safety - Gadolinium

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Management question for a subtle physical exam finding w hile you are moonlighting in the ER one day

SCOUT FROM CT SCAN

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10/16/2018 26 Knife tip MCA ACA

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

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DWI Predicts Outcome in Basilar Thrombosis

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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
  • cclusions/stenoses (VBI)
  • Clues on exam - vertigo or coma w ith any cranial nerve

abnormalities

64 year old woman w ith acute onset of WHOL

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Subtle SAH – Look in Dependent Areas

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  • 95-99% sensitive first 24 hrs
  • 50% after 1 w eek
  • 30% after 2 w eeks
  • 0% after 3 w eeks

Sensitivity of Unenhanced CT

STANDARD OF CARE IS LP WHEN CT NEGATIVE

NPV 98-100%

47 year old man w ith severe headaches for 2 w eeks

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CTA negative for aneurysm…

High Density Subarachnoid

Blood Pus Tumor Granulomas Contrast

Postcon CT

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36 year-old woman admitted w ith intractable headache CEC

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Postcon Noncon

(Empty) Delta Sign

Superior Sagittal Sinus Thrombosis

Confirm w ith MRI or CTV

T1 T2

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  • Control elevated ICP
  • Control seizures
  • Anticoagulation
  • Treat primary cause: OCPs, hypercoag states
  • Outcomes
  • Mortality ~ 30%
  • Residual deficits in ~ 30%

Venous Sinus Thrombosis - Treatment 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

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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
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THANKS

christopher.hess@ ucsf.edu andrew.josephson@ ucsf.edu