Global hypoxic-ischemic brain injury in adult

Clinical History

49 year old male patient was brought to neurology emergency unit with a history of fits and becoming unconscious.
He had been resuscitated after suffering from a cardiac arrest at a regional hospital two days ago. Initial non contrast brain CT had been reported as normal.

Imaging Findings

In DWI, there is restricted diffusion in cortical grey matter bilaterally, both thalami and basal ganglia. Same areas were low signal in T1 and high signal on T2 and FLAIR. No evidence of haemorrhages. No mass effect. MRA and MRV appeared normal. A subacute scalp hematoma is noted in the left frontal region due to injury sustained during a fit.

Discussion

Hypoxic ischemic injury in adults occurs mostly as a result of cerebral hypoperfusion following cardiac arrest, respiratory failure, drowning etc. The grey matter structures are affected. Therefore changes are seen in basal ganglia, thalami, cerebral cortex and hippocampi. The cerebellum also may be affected specially in adults [1].
These patients usually present in comatose conditions, sometimes with other neurological manifestations such as fits. The imaging is essential to confirm the diagnosis, predict the clinical outcome and evaluate extent of brain damage [2].
Diffusion-weighted (DW) imaging usually shows areas of diffusion restriction within a few hours after the causative event. Conventional T1 and T2 images may show only subtle changes initially, but after a few days these changes may become more distinct. Common areas of involvement are the basal ganglia and cerebral cortex which was seen in our patient as well [1, 2].
The involvement patterns suggesting a relatively better prognosis are ischemic changes affecting basal ganglia without cortical involvement and involvement of watershed areas. Diffuse cortical and deep grey matter ischemia, precentral gyrus involvement, diffuse white matter involvement, cerebellum and brainstem involvement are generally indicative of a poor outcome [3].
Therefore proper radiological evaluation of the patient and familiarity with various patterns of brain involvement in hypoxic ischemic injury is important in managing these patients in proper intensive care setting [4].

Differential Diagnosis List

Final Diagnosis

Hypoxic ischemic brain injury

URL:	https://www.eurorad.org/case/12243
DOI:	10.1594/EURORAD/CASE.12243
ISSN:	1563-4086