1. Brain (CNS) Infection Imaging Jalal Jalal Shokouhi – M.D. Secretary of Iranian society of radiology Secretary of Iranian society of radiology Cooperation of Iranian radiologist, president Cooperation of Iranian radiologist, president Jalaljalalshokouhi@hotmail.comJalaljalalshokouhi@hotmail.com www.Medimage.ir

2. Brain infection: 1.Ever-growing,worldwide public health problem 2.Age-old: TB, Malaria, more lethal due to multidrug-resistant strains 3.HIV is different face 4.New diseases with no known vaccine (ebola, biohazard level 4 agents) 5.Wide spread immigrations 6.World wide influenza (pandemic)

3. Radiology 1.TORCH agents  Congenital CMV  Congenital HIV  Congenital herpes 2.Aquired infections  Group B streptococcal meningitis  Citrobacter meningitis  Meningitis  Abscess  Ventriculitis  Empyema  Herpes encephalitis  Encephalitis(miscellaneous)  Rasmussen encephalitis  TB  Neurocysticercosis  Parasites  Fungal  Rickettsial  Lyme  HIV encephalitis  Opportunistic infection AIDS 3.Demyelinating diseases  MS  ADEM  Subacute sclerosing panencephalitis

4. DDx: Neonatal Periventricular Calcification Congenital CMV ToxoplasmosisLCMPseudo-TORCH CMV Microcephaly Ca++ 40-70% Gyral changes Cerebellar hypoplasia Hydrocephaly Hypodensities Abnormal WM

5. CMV

6. Congenital HIV HIV Atrophy BG Ca++ Aneurysmal changes (vasculopathy)

7. DDx: Childhood Brain Ca++ CMV Toxoplasmosis Congenital HIV DDx

8. Congenital Herpes Severe atrophy BG Ca++ Hemorrhage Hydrocephaly MRS changes

9. CMV DDx: TORCH Toxoplasma+CMVToxoplasmosis Congenital herpes

10. Group B Streptococcal Meningitis Hydrocephaly Hypo dense artery territorial(stenosis) Hemoragic venus infarct Subdurl empyema Rim enhancement Abscess

11. DDx: Neonatal Meningoencephalitis E.Coli Citrobacter HSV 2 Group B Streptococcal Meningitis

13. Citrobacter Meningitis DDx: Pediatric Cavitary White Matter Lessions Pyogenic AbcessEncephalomalaciaNAHI & WM Tears Cerebritis Abscess square Lobar cavity Marginal, septal enhancement

14. Citrobacter Meningitis

15. Meningitis DDx: Leptomeningeal Disease MetastasisNeurosarcoidosisSAHMCA infarct Normal Hydrocephaly Basal cistern involvement Arterial narrowings Exudate enhancement Cerebral edema, infarct

16. Meningitis

17. Abscess DDx: Ring-enhancing Lesions Primary tumor Resolving Clot Demyelination Metastasis Early cerebritis Late cerebritis Early cap. Late cap. Cavity Wall enhancement

18. Abscess

19. Ventriculitis Ventriculomegaly with debries Enhanced ependyma

20. Empyema DDx: Extra-axial Lesions Chronic HematomaSubdural EffusionsSubdural HygromaDural Metastases Extra-axial collection Bilateral Rim enhancement

21. Herpes Encephalitis Temporal Lobe Lesions Status EpilepticusGliomatosis Cerebri MCA IschemiaLimbic Encephalitis Normal Hypodensity Bitemporal signals (Flair, T2) Patchy or Gyral enhancemnet or No

22. Herpes Encephalitis

23. Encephalitis (Miscellaneous) DDx: Diffuse Parenchymal Lesions ACA, MCA IschemiaAstrocytomaHerpes EncephalitisStatus Epilepticus Normal High signal T1 High signal T2,Flair

24. Rasmussen Encephalitis Sturge WeberDyke MasonMELAS Atrophy, hydrocephaly No enhancement Gyral swelling Signal change: edema DDx: Cerebral Hemiatrophy

25. Tuberculosis DDx: Intracranial TB (Meningeal, Parenchymal) Bacterial Meningitis Neurosarcoidosis Pyogenic Abscess Primary Glioma (GBM) Normal Basal cistern thick enhancement Tuberculoma Ca++ Enhancement SOL (rare)

26. Tuberculosis

27. Neurocysticercosis DDx: Ring-enhancing Parenchymal Lesions Tuberculoma Pyogenic AbscessMetastases Amebic Encephalitis Hydrocephaly Ring enhancements Cyst and nidus inside Ca++ granular Granular, vesicular patterns

28. Neurocysticercosis

29. Parasites, Miscellaneous DDx: Ring-enhancing Parenchymal Lesions Matastatic Disease Cystic GBMPyogenic Abscess Neurocysticercosis Hydatid= simple cyst,no enhancement Amebic=complex, cystic hypodensities

30. Parasites, Miscellaneous Malaria Paragonimiasis

31. Fugal Disease DDx: Multiple Enhancing Brain Lesions in Immunosuppressed Patients CysticercosisMetastasesTBSeptic Emboli Granular Lacunar, cystic Edema Hemorrhage hydrocephaly Nocardiosis

32. Rickettsial Disease DDx: Multifocal White Matter Lesions M. Sclerosis Vasculitis Sarcoidosis Herpes Simplex 1 Small WM lesions May enhanced Brain edema Caudia equina enhancement

33. Lyme Disease DDx: Common White Matter Hyperintensities SarcoidosisMSLacunar InfarctVasculitis UBO periventricular Faint enhancement

34. HIV Encephalitis Lymphoma PML HSV Encephalitis DDx: Focal White Matter Abnormalities in HIV+ HHV6 Encephalitis Children Atrophy WM disease BG Ca++ Adult Atrophy,hydrocephaly No enhancement

35. HIV Encephalitis

36. Opportunistic Infection, AIDS Focal Mass in HIV+ Primary LymphomaBacterial AbscessesToxo. Hyperdense, Hypodense, Hyperintense related to: TB, PML, Toxo, Lymphoma

37. Opportunistic Infection, AIDS Cryptococcus PML: progressive multi focal leukoencephalopathy TB

38. Multiple Sclerosis ADEMVasculitisLyme DiseaseSusac Syndrome

39. Multiple Sclerosis

40. ADEM: Acute disseminated encephalomyelitis DDx: Multifocal White Matter Lesions MSAging WM LesionsFabry DiseaseBehcet UBO`s with coalescence Centri petal SOL

41. ADEM

42. Subacute Sclerosing Panencephalitis DDx: Confluent T2 Hyperintense White Matter Lesions ADEMPMLMSHIV Patchy signals Brain edema

43. Thank you for your attention