A Pediatric Radiology Textbook and Pediatric Radiology Digital Library
Pediatric Cytomegalovirus Encephalitis
Etiology: Transplacental infection of cytomegalovirus causing meningoencephalitis, periventricular white matter necrosis with calcification, cortical necrosis, disturbance of neuronal migration, ventriculomegaly, cerebellar hypoplasia, disruption of cerebellar architecture
Imaging: Timing of infection correlates with severity – early infection causes migrational anomalies, later infection causes destructive lesions and myelination delay — First and second trimester – Agyria or pachygyria or lissencephaly, cerebellar hypoplasia, ventriculomegaly — Late second trimester – Polymicrogyria, schizencephaly, mild ventriculomegaly — Third trimester – No migrational anomalies, myelin delay or destruction, abnormal white matter signal, periventricular cysts secondary to germinal matrix necrosis or hemorrhage
Imaging: Calcifications — 70% are thick and chunky and periventricular or can be fine and punctate in parenchyma and deep gray nuclei — Are nonspecific and can be due to other infections, ischemia, metabolic disorders — Seen in isolation calcifications, migrational abnormalities, white matter disease, anterior temporal cysts are nonspecific — Seen in combination calcifications, migrational abnormalities, white matter disease, anterior temporal cysts should raise concern for cytomegalovirus infection
Imaging US: Lenticulostriate vasculopathy
Imaging CT and Imaging MRI: Intracranial calcification, ventriculomegaly, white matter abnormalities (anterior temporal white matter T2 hyperintensity, anterior temporal subcortical cysts, dilated temporal horns), neuronal migration anomalies, cortical dysplasia, destructive encephalopathy with cysts in subcortical or periventricular or intraventricular locations
DDX: Toxoplasmosis – cytomegalovirus calcifications are perventricular while toxoplasmosis calcifications are random, in cytomegalovirus globes are normal and in toxoplasmosis globes are abnormal
Complications:
Treatment:
Clinical: — 1% of newborns infected with cytomegalovirus — Most common TORCH infection seen today — Microcephaly — Also have pneumonia, hepatosplenomegaly, blueberry muffin lesions on skin = petechia, purpura, mounded lesions of extramedullary hematopoesis
Radiology Cases of Cytomegalovirus Encephalitis
AP (above) and lateral (below) radiographs of the skull show bilateral thick, chunky, periventricular calcifications outlining the lateral ventricles.Coronal US of the brain (above) shows large septated cysts in the germinal matrix (germinolysis) bilaterally along with multiple periventricular echogenic foci just lateral to the anterior horns of the lateral ventricles bilaterally representing periventricular calcifications. Left sagittal (below left) and right sagittal (below right) US show branching linear echogenicities in the basal ganglia respresenting lenticulostriate vasculopathy.
Radiology Cases of Cytomegalovirus Encephalitis First and Second Trimester Infection
Axial T1 MRI without contrast of the brain (left) shows gyral thickening compatible with pachygyria and ventriculomegaly. Axial T2 MRI (right) shows increased bright signal throughout the white matter, compatible with delayed myelination. There are also several areas of punctate low signal along the periphery of the lateral ventricles posteriorly, compatible with foci of calcification, which were confirmed on GRE images (not provided).
Axial T2 MRI without contrast of the brain show thickening and abnormal sulcation of the perirolandic gray matter diffusely bilaterally. There is also evidence of perisylvian fissure syndrome bilaterally.
Radiology Cases of Cytomegalovirus Encephalitis Third Trimester Infection
