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PATTERNS OF EDEMA James G. Smirniotopoulos, M.D. Professor of Radiology and Neurology Chairman, Department of Radiology and Nuclear Medicine Uniformed.

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Presentation on theme: "PATTERNS OF EDEMA James G. Smirniotopoulos, M.D. Professor of Radiology and Neurology Chairman, Department of Radiology and Nuclear Medicine Uniformed."— Presentation transcript:

1 PATTERNS OF EDEMA James G. Smirniotopoulos, M.D. Professor of Radiology and Neurology Chairman, Department of Radiology and Nuclear Medicine Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD USA Voice: FAX: Visit us on the WEB:

2 DISCLAIMER: The opinions expressed herein are those of the author(s), and are not necessarily representative of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DOD); or the World Health Organization (WHO). Medicine is a constantly changing field, and medical information is subject to frequent correction and revision. Therefore the reader is entirely responsible for verifying the accuracy and relevance of the information contained herein. Portions herein copyright 2000 James G. Smirniotopoulos, M.D.

3 EDEMA Definitions Increase In Tissue Water Intracellular - Cytotoxic Extracellular (Interstitial, Extra Cellular Fluid ‑ Ecf) - Vasogenic - Hydrostatic (Hydrocephalic)

4 EDEMA: INCREASED TISSUE WATER CT: Decreased SPECIFIC GRAVITY -Decreased Attenuation MR: Prolongs BOTH T1/T2 T1W ‑ Decreased Signal Intensity T2W ‑ Bright

5 EDEMA: PD ‑ INCREASED SIGNAL usually > CSF except Macrocystic Encephalomalacia T2W ‑ INCREASED SIGNAL (Often <>CSF, depends on the windows and pulse sequence)

6 Interstitial Edema –Abnl. Or Absent Bbb –Plasma Ultrafiltrate (Ions, Small Proteins) Spreads From Neovascularity - Abscess - Neoplasm Localized In Infarct - No "Pump"

7 Figure

8 WHITE MATTER (Accepts Interstitial Edema) Relatively Loose Organized Tracts (Natural Conduits For Edema) Larger ECF More Compliant (To Increased Size Of ECF) Spreads Until Production = Absorption (Over Large Area)

9 GRAY MATTER (Resistant To Interstitial Edema): More Dense And Compact Small ECF (Almost Non ‑ Existent) Non ‑ Compliant (To Increased Size Of ECF)

10 CYTOTOXIC EDEMA Metabolic/Ischemic Energy Dependent Pump Metabolic Poisons: - Cn, Triethyl Tin, Hexachlorophene. Passive Exchange Across Cell Membrane Intracellular Edema –Cortical Gray Matter

11 Figure

12 ISCHEMIC EDEMA (From Ischemic Insult): Cytotoxic –Both Gray And White Vasogenic – White Matter Only – Limited By Low Perfusion

13 EDEMA LOCATIONS Edema Patterns White Matter Only: - Peritumoral (Peri ‑ Lesional) - Periventricular (Hydroceph.) Gray And White Matter - Vascular Territory (If Infarct) - Gray regional if encephalitis

14 EDEMA RIVERS (Spreads Readily): –EXTERNAL CAPSULE –EXTREME CAPSULE –UNCINATE FASCICULUS –"U" FIBERS –Centrum Semiovale –Other Association fiber tracts

15 EDEMA DAMS (Effectively Block Spread): –INTERNAL CAPSULE (Projection) –CORPUS CALLOSUM (Commissure) –GRAY MATTER - Both Deep And Cortex

16 EDEMA LOCATION White Only Peri ‑ Tumoral (Peri ‑ Lesional) White Only Periventricular White And Gray (Also Gray Only) – Vascular Territory

17 PATTERNS OF EDEMA Hydrocephalic (Hydrostatic) Edema –Extracellular (Interstitial) Edema –Distention of Ventricle –Ependymal lining rips open CSF pours into brain parenchyma Edema spreads from ventricle through white matter Chronic edema => demyelination

18 EDEMA ETIOLOGY Neoplasm/Abscess –Vasogenic (White Only) Hydrocephalus – Hydrostatic (White Only) Ischemia –Cytotoxic (Gray And White) (Also Gray - Only esp. Encephalitis) –Limited Vasogenic

19 Bibliography Bartkowski HM. Peritumoral Edema. Prog exp Tumor Res 1984; Bradac GB, Ferszt R, Bender A, Schorner. Peritumoral edema in meningiomas. A Radiological and Histological Study. Neuroradiology 28 (1986): ; Bradac G, Ferszt R, Bender A, Schorner W. Peritumoral edema in meningiomas; a radiological and histological study. Neuroradiology 1986;28: Cooper PR. Delayed Brain Injury: Secondary Insults. Central Nervous System Trauma Status Report 1985;Chap. 13: Ed. B. Cowley A. Influence of fiber tracts on the CT appearance of cerebral edema: Anatomic- pathologic correlation. AJNR Am J Neuroradiol 1983;4: Drayer BP and Rosenbaum AE. Brain Edema Defined by Cranial Computed Tomography. J Comp Assist Tomogr 1979;3(3): Finizio FS. CT and MRI aspects of supratentorial hemispheric tumors of childhood and adolescence. Childs Nerv Syst 1995; Fishman RA. Brain Edema. NEJM 1975; Gazendem J, Go KG, van Zanten AK. Composition of isolated edema fluid in cold-induced brain edema. J Neurosurg 1979;51:70-7. Kamada K, Houkin K, Hida K, Iwasaki Y, Abe H. Serial changes in metabolism and histology in the cold- injury trauma rat brain model--proton magnetic resonance imaging and spectroscopy study. Neurol Med Chir (Tokyo) 1995;35:1-7. Kimelberg HK. Astrocytic edema in CNS trauma. J Neurotrauma 1992;9 Suppl 1:S Kirkwood JR. Essentials of Neuroimaging. New York, Edinburgh, London, Melbourne: Churchill Livingstone; 1990; Milhorat TH. Classification of the cerebral edemas with reference to hydrocephalus and pseudotumor cerebri. Childs Nerv Syst 1992;8(6): Monajati A, Heggeness L. Patterns of edema in tumors vs. infarcts: Visualization of white matter pathways. AJNR Am J Neuroradiol 1982;3: O'Brien MD. Ischemic Cerebral Edema. A Review. Stroke 1979;10(6): Shapira Y, Artru AA, Qassam N, Navot N, Vald U. Brain edema and neurologic status with rapid infusion of 0.9% saline or 5% dextrose after head trauma. J Neurosurg Anesthesiol 1995;7: –EXTREME CAPSULE –UNCINATE FASCICULUS –"U" FIBERS


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