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
_________ ____________________ ___________