Journal Reading

Chintya Anugrah Suhendra S.Ked

1161050122

Dosen Pembimbing :
dr. Yosef P Siregar
Sp.Rad
KEPANITERAAN
KLINIK RADIOLOGI
PERIODE 29 AGUSTUS 1 OKTOBER
2016

Introduction
Paramyxovirus infects human &
horses

Hendra
Virus
(HeV)

7 Case

Outbreaks :
1994: Suburb Brisbane, Australia
human
2008-2011 : Queensland, Australlia
human
July August 2011 : horses

Horses consume food

contaminated by uterine

4 death case

fluids and aborted foetal

3
Meningoencepha
litis

1 Respiratory
illness

tissue from fruit bats; the

natural hosts of HeV

Material & Methods

MRI
: 1,5 T Siemens Magnetom Avanto Unit
Contrast
: Gadolinium chelate (Magnevist/ Omniscan)
dose 0,1 ml/kgBB

Case
1
Case
2
Case
3

Present to hospital: 5 days after (+) flu like

symptoms
Horse contact (+) : 2 weeks before sick
MRI exam: on day 2, 7, 15, 22, 39 of hospital
admission
Time death: on day 40 of hospital admission
Present to hospital: 2 weeks after (+) flu like
symptoms
Discharged from hospital: on day 33
MRI exam: on day 9, 15, 22, 32 of hospital
admission, post-discharge follow up 2, 4, 11, 31
months
(+) symptom after 48 hours prophylaxis
Horse contact (+) : 9 days before prophylaxis
MRI exam: on day 1, 7 of hospital admission
Time death: on day 7 of hospital admission

Material & Methods

Common treat for all patient:
1. HeV confirm by serology findings
2. EEG Meningoencephalitis
3. Drug : Ribavirin

Result
3 Case

MRI Findings:
T2 Flair :
Hyperintense
Non-enhancing cortical lesions had a well
circumscribed
Purely cortical plaque-like appearance
True diffusion restriction
Leptomeningeal enhancement
Location : early involvement precuneus
cortex (grey matter) spread to basal
ganglia dan cerebral cortex (white matter)

Result

Temporal pattern of changes in fatal acute HeV encephalitis (case 1). Axial,
T2-FLAIR images (a) 2 days after admission, only a few cortical lesions are
evident. (b) By day 15 of presentation, the cortical lesions demonstrate
marked progression in number and extent, with deep white matter sparing.
(c) On day 22 of presentation, the cortical lesions have progressed further,
with early widespread white matter changes. (d) On day 36
of presentation,
Clinical
radiology,

2012

Result
Severe
case
(case 1
& 3)
Mild
case
(case 2)

(+) white matter involvement

Brain perfusion T2 FLAIR :
Hyperintense
Restricted diffusion
< CBF
< CBV
(+) Vasculitis acute ischemia

Cortical involvement was markedly less

Showed gradual disappearance of the lesions over a month
DWI Normalization but theres subtle cortical laminar
necrosis had developed in the precuneus & temporal lobe

Result
Case 2

Case 1

Axial, T2-FLAIR image on

day 22 of presentation
demonstrates a subtle focal
hyperintense lesion in the
left precuneus, sparing the
white matter.

T2-FLAIR: On day 22
of presentation, the
cortical lesions have
progressed further, with
early widespread white
matter changes.

Case 3

T2-FLAIR sequence.
Multiple focal
hyperintense lesions are
present in the grey and
white matter
Clinical
radiology,
2012

Result
Case 2

Axial, T1-weighted
image demonstrates
subtle hyperintensity,
consistent with cortical
laminar necrosis

Case 1

Unenhanced, axial, T1-weighted image on

day 36 of presentation demonstrates gyriform
hyperintense signal, consistent with cortical
laminar necrosis. The patient died 1 day after
this examination

Clinical radiology,
2012

Result
NAA (NAcetylaspartic
acid) < Choline
Lactate doublet (+)

Clinical radiology,
2012

Result

Case 1: DWI (B = 1000)

Case 3: DWI (B = 1000)

Numerous tiny lesions which
demonstrate true restricted
diffusion are present.
Clinical radiology,
2012

Result

Case 1: the corresponding

apparent diffusion
coefficient (ADC) map,
confirm true restricted diffusion
within the cortical lesions.

Case 3: ADC map

shows respective foci of
decreased signal
Clinical radiology,
2012

Result

Case 3:
(d) Focal areas of reduced CBV are present, and correspond to the foci of T2-FLAIR and
DWI abnormality.

(e) Focal areas of reduced CBF are present, also corresponding anatomically to the
abnormal foci. This pattern is suggestive of diffuse cerebral vasculitis with
secondary infarctions.

Clinical radiology,
2012

Discussion
MRI abnormalities correlate well with the clinical
course

The striking initial cortical selectivity in HeV

encephalitis could help differentiated between HeV
& other infective encephalitis

Discussion

Karena level
ribavirin < pada
CSF sehingga
efek antiviral
neuronal tidak
ada

Acute
Hendra
Virus

Acute
Nipah
Virus

Tissue
tropism :
neuron cell

Tissue
tropism :
endothelial
cell
vasculitis

Grey matter
white
matter

White
matter
grey matter

Chronic HeV: (+)

endothelial tropism
vasculitis

Karena level
ribavirin
konsentras
inya >
pada
intravaskul
ar sehingga
efeknya
lebih
berkhasiat

Conclusion
MRI abnormalities were similar in all three cases;
1. Lesions confined to the cortex & all cases
appeared to involve the precuneus
2. In both fatal cases MRI change mirrored
clinical course with rapid progression of
cortical lesions

the
the

3. White matter lesions were a relatively delayed

finding in both fatal cases
4. Perfusion studies at this time demonstrated
multifocal infarction secondary to florid
vasculitis, which is another prominent feature
of HeV encephalitis

THANK YOU

MRI

Mild

Severe

Case 2

Case 1

Case 3

PH:
PH:
PH:
PH:

PH: 1

T2 FLAIR
PH: 22

2
15
22
36

Pulang 6 month
T1

V PH: T1
PH: 36

DWI

ADC