CNS PathologyCNS Pathology

RT 91 RT 91

Fall 2011Fall 2011

FinalFinal

CRANIAL FRACTURESCRANIAL FRACTURES

Cranial FracturesCranial Fractures Cerebral fractures usually occurs to Cerebral fractures usually occurs to

fractures of the calvaria of the skullfractures of the calvaria of the skull 3 types of cranial fractures3 types of cranial fractures

____________- straight and sharply defined____________- straight and sharply defined• Is 80% of all cranial fracturesIs 80% of all cranial fractures

____________- curvilinear density____________- curvilinear density

____________- Air fluid levels are indicative ____________- Air fluid levels are indicative • Hard to diagnosis radiographicallyHard to diagnosis radiographically

Cranial FracturesCranial Fractures

Location of FX is more important that the Location of FX is more important that the extent of the FXextent of the FX If FX crosses artery a bleed can occur If FX crosses artery a bleed can occur

causing a hematomacausing a hematoma

Fx that enters mastoid air cells or sinus can Fx that enters mastoid air cells or sinus can cause an infection that can result incause an infection that can result in• Meningitis Meningitis • EncephalitisEncephalitis

_______ Fractures_______ Fractures Non branching lines that Non branching lines that

are intensely radiolucentare intensely radiolucent

Vascular markings are Vascular markings are occasionally mistaken for occasionally mistaken for fracturesfractures

Fracture appears more Fracture appears more translucent and translucent and transverses the full transverses the full thickness of skullthickness of skull

SuturesSutures

____________________________________

__________ Fracture__________ Fracture The fractured edges The fractured edges

________________

Usually caused by a high Usually caused by a high velocity impact with a velocity impact with a small objectsmall object

Can cause bleeding into Can cause bleeding into ______________ space______________ space

Best demonstrated with Best demonstrated with CR __________to the FXCR __________to the FX

_____________ Skull FX_____________ Skull FX

_______________Fracture_______________Fracture Very difficult to demonstrate with x-rayVery difficult to demonstrate with x-ray

__________________ in sphenoid sinuses__________________ in sphenoid sinuses Clouding of ________________________________Clouding of ________________________________

Often X-table lateral is done to demonstrate thisOften X-table lateral is done to demonstrate this CT & MRI are most often used for this type CT & MRI are most often used for this type

TRAUMATIC DISEASETRAUMATIC DISEASE

MeningesMeninges Has protective membranes that Has protective membranes that enclose the brain and spinal cordenclose the brain and spinal cord

Dura Mater- outer most layerDura Mater- outer most layer• Tough and fibrousTough and fibrous

Arachnoid = middle layerArachnoid = middle layer• Has appearance of cobwebsHas appearance of cobwebs

Pia mater = innermost layerPia mater = innermost layer• highly vascular and closely highly vascular and closely

adhered to cortex and spinal adhered to cortex and spinal cordcord

Subarachnoid space = wide Subarachnoid space = wide space between arachnoid and space between arachnoid and pia materpia mater

• Filled with CSFFilled with CSF• Bathes brain & spinal cord with Bathes brain & spinal cord with

nutrientsnutrients• Cushions against shocks and Cushions against shocks and

blowsblows

Meninges DiagramMeninges Diagram

Ventricular Ventricular SystemSystem

Four irregular Four irregular interconnected- fluid-interconnected- fluid-containing cavitiescontaining cavities

Cerebrospinal fluid (CSF) = Cerebrospinal fluid (CSF) = tissue fluid of the brain and tissue fluid of the brain and spinal cord that surrounds spinal cord that surrounds and cushions CNSand cushions CNS

Ventricles communicate with Ventricles communicate with each other through each other through connecting channelsconnecting channels

Lateral ventricles = one on Lateral ventricles = one on each side of MSP in each side of MSP in corresponding hemispheres corresponding hemispheres of cerebrumof cerebrum

Ventricular Ventricular System System

Interventricular foramen = Interventricular foramen = connects lateral ventricles to connects lateral ventricles to third ventriclethird ventricle

Also called foramen of Also called foramen of MonroeMonroe

Third ventricle is slitlike cavity Third ventricle is slitlike cavity somewhat quadrilateral in somewhat quadrilateral in shapeshape

Situated in MSP, just Situated in MSP, just inferior to lateral ventriclesinferior to lateral ventricles

Cerebral aqueduct = connects Cerebral aqueduct = connects third and fourth ventricle; also third and fourth ventricle; also called aqueduct of Sylviuscalled aqueduct of Sylvius

Cerebral ______________Cerebral ______________ Is an injury to the brain tissue caused by a Is an injury to the brain tissue caused by a

____________ of the brain within the ____________ of the brain within the calvaria after ______________________calvaria after ______________________

Occurs when brain contacts rough skull Occurs when brain contacts rough skull surfaces such as _______&___________surfaces such as _______&___________ PT usually loses consciousness and cannot PT usually loses consciousness and cannot

remember traumatic eventremember traumatic event Persitent LOC over 24 hrs is a coma and can Persitent LOC over 24 hrs is a coma and can

be fatalbe fatal

Cerebral Cerebral ContusionContusion

Clinical symptoms:Clinical symptoms: DrowsinessDrowsiness ConfusionConfusion AgitiationAgitiation HemiparesisHemiparesis Unequal pupil sizeUnequal pupil size

Treatment:Treatment: PT is hospitalizedPT is hospitalized

• Prevent shockPrevent shock

If there is swelling If there is swelling medication is given to medication is given to decrease cranial decrease cranial pressurepressure

• Control edemaControl edema• Draniage of hematomaDraniage of hematoma

Surgery is usually not Surgery is usually not necessarynecessary

Cerebral ________________Cerebral ________________

HematomasHematomas Brain trauma often resulting in a hemorrhaging Brain trauma often resulting in a hemorrhaging

from a ruptured ______________________from a ruptured ______________________ __________bleeding occurs more slowly than arterial __________bleeding occurs more slowly than arterial

bleedingbleeding _________bleed accumulates fast & causes _________bleed accumulates fast & causes

neurologic symptoms & comaneurologic symptoms & coma Both can cause edema in the brain and cause an Both can cause edema in the brain and cause an

increase in intracranial pressureincrease in intracranial pressure

Skull does not allow for expansion and pressure Skull does not allow for expansion and pressure forces brain toward open space (foramen forces brain toward open space (foramen magnum)magnum)

Can result in major consequences & death if not Can result in major consequences & death if not treated quicklytreated quickly

______________Hematomas______________Hematomas

Highest mortality relate of the hematomasHighest mortality relate of the hematomas Even when treated quickly mortality rate is 30%Even when treated quickly mortality rate is 30%

Results from a torn _________ and its branchesResults from a torn _________ and its branches Most often occurs from a FX of the _______ boneMost often occurs from a FX of the _______ bone 80% of cases conventional radiograph shows fracture80% of cases conventional radiograph shows fracture

Usually _______________ with blood pooling Usually _______________ with blood pooling between bones of the skull & _______________between bones of the skull & _______________

____________Hematoma____________Hematoma

Usually a shift of midlineToward ________ side

CT shows increased density

Emergency surgicaldecompression is required to relieve cranial pressure

_______________ Hematomas_______________ Hematomas

Between the __________&___________Between the __________&___________ Caused by blunt trauma to frontal or occipital Caused by blunt trauma to frontal or occipital

lobes and can tear ____________________lobes and can tear ____________________

Pushes brain away from skull across Pushes brain away from skull across midline (including ventricles)midline (including ventricles)

_____________Hematoma_____________Hematoma

Occurs more slowlyBecause it is a ________Hemorrhage.

On CT appears as a curvilinear area of Iincreased density on portions or all of the cerebral hemispheres

______________Hematomas______________Hematomas

Subacute stage (up to several days)Subacute stage (up to several days) Appears on CT as a decreased density or Appears on CT as a decreased density or

isodense fluid collectionisodense fluid collection

In chronic state (2-3 weeks)In chronic state (2-3 weeks) The surface of the hematoma becomes The surface of the hematoma becomes

concaveconcave Delayed coma cn occurDelayed coma cn occur

Symptoms of HematomasSymptoms of Hematomas

HeadachesHeadaches

AgitationAgitation

DrowsinessDrowsiness

Gradual radiograph deficitsGradual radiograph deficits

Treatment of HematomasTreatment of Hematomas In small hematomas without inclination to In small hematomas without inclination to

rebleedrebleed the hemorrhage is reabsorbed naturally the hemorrhage is reabsorbed naturally no treatment is necessaryno treatment is necessary

Severe casesSevere cases Require surgical ligationRequire surgical ligation Evacuation of hematoma to prevent herniationEvacuation of hematoma to prevent herniation

Less invasive treatment may includeLess invasive treatment may include Drug therapyDrug therapy Intraventricular catheter to remove CSF, which may Intraventricular catheter to remove CSF, which may

cause herniationcause herniation

Gunshot WoundsGunshot Wounds

Gunshot WoundGunshot Wound

______________________________

Can be _______________ or ________________Can be _______________ or ________________ Refers to an excessive amount of fluid in the Refers to an excessive amount of fluid in the

ventriclesventricles Two typesTwo types

______________________________________________________________• Interferes or blocks normal CSF circulation from the ventricles Interferes or blocks normal CSF circulation from the ventricles

to the subarachnoid spaceto the subarachnoid space __________________________________________________________________

• Poor absorption of the CSF by the arachnoid VilliPoor absorption of the CSF by the arachnoid Villi Least common cause is from overproduction of CSFLeast common cause is from overproduction of CSF

__________________________________________________

Non-communicatingNon-communicating Can be congenitalCan be congenital Can be from tumor Can be from tumor

growthgrowth Trauma (hemorrhage)Trauma (hemorrhage) InflammationInflammation

CommunicatingCommunicating Can come with Can come with

increased cranial increased cranial pressurepressure

Raised intrathoracic Raised intrathoracic pressure impairing pressure impairing venous flowvenous flow

Inflammation from Inflammation from meningitismeningitis

Subarachnoid Subarachnoid hemorrhagehemorrhage

Radiographic AppearanceRadiographic Appearance

Generalized enlargement of the ventricular systemGeneralized enlargement of the ventricular system

PA radiograph can reveal separation of the PA radiograph can reveal separation of the ______________________

CT clearly demonstrates ventricular dilatation CT clearly demonstrates ventricular dilatation

MRI is more specific in demonstrating the underlying MRI is more specific in demonstrating the underlying cause of obstruction or in excluding obstructioncause of obstruction or in excluding obstruction

Ultrasound is useful in utero and in infantsUltrasound is useful in utero and in infants Sound waves transverse open fontanelsSound waves transverse open fontanels

HydrocephalusHydrocephalus

HydrocephalusHydrocephalus

Hydrocephalus Clinical SymptomsHydrocephalus Clinical Symptoms

The cranial size is The cranial size is enlargedenlarged

Scalp veins distendedScalp veins distended Skin of scalp thin, Skin of scalp thin,

fragile and shinyfragile and shiny Neck muscles Neck muscles

underdevelopedunderdeveloped Severe casesSevere cases

Orbital roofs are Orbital roofs are depresseddepressed

Eyes displaced Eyes displaced downwardsdownwards

•In adults •ALOC•Ataxia•Incontinence•Decreased intellectual •capabilities

Treatment of HydrocephalusTreatment of Hydrocephalus Placement of a ________Placement of a ________

Internal jugular, heart or Internal jugular, heart or peritoneumperitoneum

Contains one way valve to Contains one way valve to prevent backflow of blood prevent backflow of blood into ventriclesinto ventricles

Radiographs taken to Radiographs taken to verify _______________verify _______________

CT or MRI done to CT or MRI done to evaluate success of evaluate success of treatmenttreatment

Hydrocephalus in InfantsHydrocephalus in Infants

Affects 1 of every Affects 1 of every 1000 newborns1000 newborns

Long maturation of Long maturation of CNSCNS

Can be caused by Can be caused by maternal & fetal maternal & fetal infections, fetal infections, fetal hypoxia, irradiation, hypoxia, irradiation, chemical agents and chemical agents and mechanical forcesmechanical forces

Vascular DiseaseVascular Disease

________________________________________________

Is an atherosclerotic disease affecting blood Is an atherosclerotic disease affecting blood supply to the brainsupply to the brain

______________leading cause of death in U.S.______________leading cause of death in U.S. 2 types of stroke:2 types of stroke:

______________________________________________________________________ Both CT and MRI distinguish between the two Both CT and MRI distinguish between the two

typestypes MRI is especially sensitive to infarction within hours of MRI is especially sensitive to infarction within hours of

onsetonset CT, at times appears negative for a day or soCT, at times appears negative for a day or so

Carotid duplex and MRA are also useful in the Carotid duplex and MRA are also useful in the diagnosis of a strokediagnosis of a stroke

________________ Stroke________________ Stroke Blood clot blocks a blood vessel in the brainBlood clot blocks a blood vessel in the brain Is the majority of strokesIs the majority of strokes

Two types:Two types: ____________________ of cerebral artery____________________ of cerebral artery

• Blood clot that blocks a blood vesselBlood clot that blocks a blood vessel ____________________ of the brain____________________ of the brain

• Is a mass of undissolved matter (solid, liquid or gas) present Is a mass of undissolved matter (solid, liquid or gas) present in a blood vessel brought there by blood currentin a blood vessel brought there by blood current

Diagnosed with CT and MRIDiagnosed with CT and MRI Angiography can be used if other modalites are Angiography can be used if other modalites are

questionablequestionable

Symptoms of ________ Symptoms of ________ __________Stroke__________Stroke

Sypmtoms come on over horus to daysSypmtoms come on over horus to days ConfusionConfusion HemiplegiaHemiplegia AphasiaAphasia

May be preceded by a temporary episode of May be preceded by a temporary episode of nerurologic dysfunction called transient ischemic nerurologic dysfunction called transient ischemic attack (TIA)attack (TIA) Includes hemiparesis, monocular blindness- clears up Includes hemiparesis, monocular blindness- clears up

in about 2 hoursin about 2 hours

Ischemic Stroke: from ______Ischemic Stroke: from ______ ___________ onset of symptoms without ___________ onset of symptoms without

warningwarning

Mortality rate is_______________Mortality rate is_______________

Prognosis depends on location, extent, age, and Prognosis depends on location, extent, age, and general healthgeneral health Complete recovery is rareComplete recovery is rare Deficits remaining after 6 months are likely to be Deficits remaining after 6 months are likely to be

permanentpermanent

TreatmentTreatment Bed rest Bed rest Clot blockers within 3 hours (recombinant tissue Clot blockers within 3 hours (recombinant tissue

plasminogen activator (rtPA)plasminogen activator (rtPA)

Ischemic StrokeIschemic Stroke

________________ Stroke________________ Stroke Occurs from a __________ in the diseased Occurs from a __________ in the diseased

blood vesselblood vessel Typically weakened from atheroscleosis from Typically weakened from atheroscleosis from

hypertensionhypertension

Sudden and often lethal because it comes on so Sudden and often lethal because it comes on so suddenlysuddenly

Accounts for _____________of all CVA’s Accounts for _____________of all CVA’s

Two types:Two types: _______________-&__________________________________-&___________________

Hemorrahgic StrokeHemorrahgic Stroke

Most occur in the ________ and bleed into Most occur in the ________ and bleed into lateral ventriclelateral ventricle

Most often preceded by an intense headache Most often preceded by an intense headache and vomitingand vomiting

LOC follows in minutes and leads to LOC follows in minutes and leads to contralateral hemiplegia or deathcontralateral hemiplegia or death

Prognosis is poorPrognosis is poor ___________ die day after stroke___________ die day after stroke ___________die within a few weeks, usually from ___________die within a few weeks, usually from

another vessel ruptureanother vessel rupture

Treatment ofTreatment ofHemorrahgic StrokesHemorrahgic Strokes

SurgerySurgery Preceded by a surgical angiogramPreceded by a surgical angiogram

If surgical intervention is postponed so will If surgical intervention is postponed so will the angiogramthe angiogram

Hemorrahgic StrokeHemorrahgic Stroke

Neoplastic DiseaseNeoplastic Disease

___________ _______________________ ____________

Pituitary AdenomaPituitary Adenoma

Acoustic NeuromaAcoustic Neuroma

Acoustic NeuromaAcoustic Neuroma

Metabolic DiseaseMetabolic Disease

__________ __________ ____________________•X-ray of affected bones show X-ray of affected bones show

cortical thickening with a cortical thickening with a coarsecoarse

•Thickened trabecular patternThickened trabecular pattern

•Often called ___________ Often called ___________

appearanceappearance

•Mixed areas of ___________ Mixed areas of ___________ &__________________ areas&__________________ areas

________________Disease________________Disease

5454

__________ Disease__________ Disease1.1. __________________________ disorder of unknown cause disorder of unknown cause

2.2. Has two stages:Has two stages:1.1. ______________________________

2.2. ______________________________

3.3. Fairly common in elderly Fairly common in elderly

4.4. Affects men twice as frequently as womenAffects men twice as frequently as women

MalignancyMalignancy

_________ ____________________ ___________