Ensefalit

Özet

Ensefalit, beyin parankiminin enfeksiyöz veya immün aracılı inflamasyonudur; BT bulgusu etkeni tek başına tanımlamaz ve erken inceleme normal olabilir. Akut BT'nin öncelikli rolü ödem, kitle etkisi, kanama ve alternatif yapısal nedenleri hızla saptamaktır; enfekte parankimde ödem kaynaklı hipodensi ve şişme görülebilir. MRG, özellikle erken parankim değişikliği ve hemorajik küçük odaklarda BT'den daha duyarlıdır. Normal BT tanıyı dışlamaz; tedavi gecikmesi morbidite ve mortaliteyi artırmaktadır.

Faz ve pencere

Kontrastsız tanısal

Medial temporal lob ve insulada asimetrik kortikal/subkortikal hipodensi, gri-beyaz ayrımının silinmesi, giral şişme ve sulkus daralması izlenebilir; ileri hastalıkta belirgin ödem, kitle etkisi ve peteşiyal ya da daha belirgin kanama görülebilir. İlk BT normal olabilir.

Önerilen pencereler: Beyin (G 80 / M 40), İnme (G 40 / M 40).

BT bulguları

• Hipodensite — parankimde ödem kaynaklı düşük dansite; enfektif ensefalitlerde yaygın ödem ile birlikte görülebilir.
• Bazı enfeksiyonlarda odaklı olarak sınırlı kalan veya yaygın parankimal ödem ve şişme görülebilir.
• Gri-beyaz ayrım kaybı — kortikal şişme ve hipodensite nedeniyle korteks ile komşu beyaz cevher sınırının silikleşmesi.
• Etkilenen bölgede parankimal şişme ve kitle etkisi nedeniyle sulkus basılması veya bazal sisternlerin silikleşmesi görülebilir.
• Hemorajik odak — temporal veya insüler parankimde noktasal/yamalı hiperdens kan; küçük peteşiler BT'de gözden kaçabilir.
• Kontrastlı incelemede leptomeningeal boyanma izlenebilir; bu bulgunun yokluğu ensefaliti dışlamaz.
• Yaygın ödem örüntüsü — bazı etkenlerde tek lob yerine bilateral veya yaygın parankim hipodensitesi ve şişme gelişebilir.

Normalde

Ensefalitte BT normal olabileceğinden, medial temporal lobların BT’de simetrik görünmesi tek başına ensefaliti dışlamaz. Ensefalitte parankimal ödem, düşük atenüasyona ve bazen şişmeye yol açabilir.

Ayırıcı tanı

HSV ensefaliti büyük damar inmesini taklit edebilir; damar alanı dışında yerleşen hemorajik lezyonlar ensefalit olasılığını düşündürür.

Otoimmün limbik ensefalit

medial temporal şişme yapabilir; BT özgül değildir, MRG ve klinik/serolojik bağlamla enfeksiyöz HSV'den ayrılır.

Periiktal değişiklik

nöbet sonrası kortikal hipodensite ve şişme olabilir; nöbet ağıyla ilişkili dağılım gösterebilir ve seri görüntülemede gerileyebilir.

Gliom veya lenfoma

temporal lob tümörleri ensefalite benzer şekilde ortaya çıkabilir; düşük dereceli gliomlar özellikle merkezi sinir sistemi enfeksiyonlarını taklit edebilir ve seri görüntülemede statik değişiklikler, ensefalitte beklenen zaman içindeki değişimden ayrılmasına yardımcı olur.

Toksik-metabolik ensefalopati

bilateral simetrik derin gri cevher veya yaygın değişiklikler yapabilir; tipik asimetrik medial temporal HSV dağılımı beklenmez.

Tuzaklar

• Erken HSV ensefalitinde kontrastsız BT normal olabilir; temporal hipodensite görülmemesi klinik şüpheyi sonlandırmaz ve MRG daha duyarlıdır.
• HSV ensefaliti büyük damar inmesini taklit edebilir; hemorajik lezyonların damar alanı dışında yerleşip yerleşmediğini değerlendirin.
• Ensefalitte nadiren de olsa parankimal kanama veya dokuda yıkım görülebilir; BT'de kanamanın olmaması hemorajik ensefaliti tamamen dışlamaz.
• Medial temporal lezyonlar yalnızca HSV ile ilişkili değildir; otoimmün limbik ensefalit, nöbet sonrası değişiklikler ve temporal lümörler de benzer radyolojik görünüm oluşturabilir.

Kendini dene

1. Ensefalit şüpheli bir hastanın ilk kontrastsız BT incelemesi normal bulunmuştur. Bu durumda aşağıdakilerden hangisi doğrudur?

   • Tanı kesinlikle dışlanır
   • Tedavi geciktirilmemelidir, MRG daha duyarlıdır
   • BOS analizi yapılmasına gerek yoktur
   • Hasta güvenle taburcu edilir
   Cevabı göster

   Tedavi geciktirilmemelidir, MRG daha duyarlıdır. S5: 'CT is often normal in both meningitis and encephalitis'. Normal BT bulgusu enfeksiyonu dışlamaz; MRG daha duyarlıdır ve empirik tedavi gecikmemelidir (S31).

2. Ensefalit şüpheli bir hastanın ilk kontrastsız BT'si normal çıkmıştır. Bu bulgu için en doğru yorum aşağıdakilerden hangisidir?

   • Erken hastalığı kesin olarak dışlar
   • Tanısal değeri yoktur, hasta izlenmez
   • BT tanıyı dışlamaz, MRG ve BOS değerlendirmesi gereklidir
   • Otomatik olarak tümör tanısı gerektirir
   Cevabı göster

   BT tanıyı dışlamaz, MRG ve BOS değerlendirmesi gereklidir. S5: 'CT is often normal in both meningitis and encephalitis'. Erken BT normal olabilir; tanı için MRG ve BOS/moleküler testler gereklidir.

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 17 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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