Presentation
Post cardiopulmonary resuscitation for 3 cycles after massive post-partum hemorrhage.
Patient Data
Diffuse cerebral edema with effacement of the CSF-containing spaces. Cortical grey matter attenuation is markedly decreased with a loss of normal grey-white differentiation.
White cerebellum sign - apparent high attenuation of the cerebellum and brainstem relative to the cerebral hemispheres.
Basal cisterns are effaced. No acute intracranial bleed.
Relatively symmetrical hyperintensities on T2WI/FLAIR and restricted diffusion at bilateral fronto-parietal lobes (perirolandic region), bilateral occpital cortices, splenium of corpus callosum as well as a few foci at bilateral lentiform nuclei.
A few areas of hyperintensities on T2WI/FLAIR at bilateral head of caudate nuclei, bilateral hippocampal heads and bilateral cerebellar hemispheres. These areas have corresponding high signal intensities on DWI without the accompanied low signal intensities on ADC map, suggestive of pseudonormalization.
Swelling of grey matter gyri in bilateral cerebral hemispheres, predominantly affecting the parieto-occipital lobes. Ventricles and basal cisterns are effaced.
Annotated images on CT and MRI to show the relevant imaging findings.
Case Discussion
Hypoxic-ischemic damage in adults, also known as hypoxic-ischemic encephalopathy, has profound and serious neurological outcome. The most common etiology is secondary due to cardiac arrest, like in this case, and usually has history of cardiopulmonary resuscitation.
The initial CT brain was performed at 3 days post anoxic event and the MRI brain was performed after 7 days.
The typical affected areas are the vulnerable areas, such as perirolandic cortex, primary visual cortex (medial occipital lobes), basal ganglia and cerebellum. which are demonstrated in this case.
Some of the high signal intensities on T2WI/FLAIR without the corresponding restricted diffusion are due to pseudonormalization of ADC, which usually occurs after approximately one week from the initial anoxic event.
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