NEURO IMAGING

1
NEURO IMAGING
Dr. Francis Neuffer University of South
Carolina Radiology Department
2
GOALS AND OBJECTIVES

• Review major imaging modalities of neuro imaging.
  
• CT MR ultrasound angiography
• Understand the strengths of each modality.
• Apply to optimal modality to common pathologic
  conditions.
• Identify classic images of disease states of
  vascular, traumatic, infectious and neoplastic
  diseases.

3
NEURO IMAGING USING CT
4
CT SCANNER
COMPUTED TOMOGRAPHY
5
DIGITAL SCOUT SHOWING BEGINNING AND END OF CT
SCAN.
6
HOW THE CT SCANNER WORKS
7
3
7
6
4
8
2
1
3
7
3
4
4
6
9
EARLY CT IMAGING
10
BONE WINDOW
BRAIN WINDOW (SOFT TISSUE)
Gray
Black
White
-125
50
225
0
11
NEURO IMAGING USING MR
12
MR HAS ADVANTAGE OF MULTI PLANAR IMAGING.
13
MAGNETIC RESONANCE

• Hydrogen protons align in magnetic field
• Radio frequency
• excitation and
• transmission
• No ionizing radiation

14
HOW MR WORKS
RF

15
MR SIGNAL

• Determined by tissue response to RF/magnetic
  field
• 2. Tissues resonate a signal after the RF pulse
• Examples
• How long a tissue resonates is a T2
  characteristic
• How quickly a tissue responds is a T1
  characteristic

16
T1 SCAN
MR SIGNAL
T2 SCAN
SCANS ARE MADE TO SEPARATE TISSUE BASED ON THEIR
T1 AND T2 TIMES.
17
MRI TECHNIQUE

• There are many different MR sequences which are
  all based on the T1 and T2 effect.
• Examples
• T1, T2, FLAIR, Diffusion,

18
VARIOUS MRI SEQUENCES
T1 (white matter)
T2 (CSF/edema)
FLAIR (edema)
Diffusion (edema-acute CVA)
19
NEURO IMAGING USING VASCULAR ULTRASOUND
20
NORMAL CEREBRAL ARTERIOGRAM
NORMAL DOPPLER ULTRASOUND
21
CAROTID ARTERY Color Doppler
22
VASCULAR ANATOMY
ARTERIAL CATHETER
Anterior cerebral
Middle cerebral
Cavernous carotid
Basillar artery
ECA
ICA
Carotid bulb
Vertebral artery
ECA
CCA
ICA
CCA
VENOUS INJECTION
23
VASCULAR ANATOMY
ACA
MCA
MCA
BA
24
VASCULAR DISTRIBUTIONS
Anterior Cerebral Artery
Middle Cerebral Artery
Posterior Cerebral Artery
25
ANATOMY
Basilar Artery
Supracellar Cistern
Temporal Horn lateral ventricle
Pons
4th Ventricle
Cerebellum
26
ANATOMY
Anterior Horn Lateral ventricle
Caudate Nucleus
Internal capsule
Lentiform nucleus
Occipital Lobe
27
ANATOMY
3rd ventricle
Atria Lateral Ventricle
Sylvian fissure
Thalamus
Falx cerebri
28
ANATOMY
Frontal lobe
Body lateral ventricle
Parietal lobe
Falx cerebri
Occipital lobe
29
ANATOMY
Gyrus
Centrum Semiovale
Sulcus
Superior Sagittal Sinus
30
WHO ARE THE PATIENTS ?

• VASCULAR INSULT
• TRAUMA
• INFECTIOUS WORKUP
• MALIGNANCY WORKUP

31
WHO ARE THE PATIENTS ?

• ACUTE CVA

• 85 ISCHEMIC
• 15 HEMORRAGHIC
• TREATMENT DIFFERENCE
• ANTICOAGULATION FOR ISCHEMIC CVA

32
STROKE

• Ischemic
• Large artery atherosclerosis internal carotid
  disease
• Cardioembolism
• Small vessel ischemia
• Hemorrhagic

33
STROKE INTERVENTION

• Thrombolytic therapy to salvage ischemic brain at
  the border of the infarct zone.
• Who benefits and how to select?

34
STROKE INTERVENTION

• Time constraints
• 3-6 hour window
• Risk of hemorrhagic conversion
• Thrombolytic therapy

35
(No Transcript)
36
catheter
37
(No Transcript)
38
Comparison of infarct zone and ischemic zoneto
identify treatment candidates
GOAL FOR IMAGING
39
IMAGING IS EVOLVING TO ASSESS ISCHEMIA /
INFARCT ZONE
40
CT OF ISCHEMIC STROKE

• EARLY
• Often normal
• Sulcal effacement asymmetry
• Loss of grey/white differentiation

41
CT OF ISCHEMIC STROKE
1 DAY POST
2 DAY POST
42
CT vs MR
? Abnormality on CT
43
T1 SCAN
T2 SCAN
44
DIFFUSION MR
Based on local changes of intracellular water
balance in ischemic zone Intracellular edema
due to NaK pump failure.
45
MRI FINDINGS OF ACUTE STROKE
CT
T1 (hypointense)
T2 (hyperintense)
FLAIR (hyperintense)
Diffusion (hyperintense)
46
MR vs CTIN EARLY CVA

• MR LIMITATIONS
• COMPLEX MR SIGNAL OF HEMORRHAGE
• RELATED TO HEMAGLOBINFe EFFECTS
• ACCESS
• CT IS IN HOUSE FOR ER PATIENTS
• UNSTABLE PATIENT-PATIENT MOTION
• MORE A PROBLEM IN MR (LONGER SCAN
  TIME)
• CT READILY VISUALIZES BLOOD PRODUCTS

47
STENOSIS
SOURCE OF EMBOLIC MATERIAL
NORMAL
48
DOPPLER ULTRASOUND
NORMAL
ABNORMAL
49
CAROTID ARTERY Color Doppler
50
OCCLUDED LT. MCAMR arteriogram
Normal
51
INTRACEREBRAL HEMORHAGEHYPERTENSIVE EVENTS

• Acute Blood is dense on CT

Pontine Hemorrhage
Right Parietal Hemorrhage
Thalamic Hemorrhage
52
MR HEMORRHAGEvaried appearance by age of blood
53
SUBARACHNOID HEMORRHAGE

• Blood in the subarachnoid space
• Between the Pia Arachnoid
• CT acute blood, increased density
• Rupture of cerebral aneurysm
• Worst Headache of Life
• Location basal cisterns, sylvian fissure,
  cortical sulci.

54
SUBARACHNOID HEMORHAGE
Increased density
Normal
55
CAROTID AND BASILAR ANEURYSMS
56
IMAGING OF STROKE

• CT
• Better identification of acute hemorrhage
• Availability
• Decrease expense
• Decrease time
• Less contraindications
• MRI
• More sensitive to early changes of stroke ie.
  edema

57
WHO ARE THE PATIENTS?

• HEAD / SPINE TRAUMA

58
SUBDURAL HEMATOMA

• Venous bleeding from bridging veins which
  connect cerebral cortex to dural sinuses
• Location cerebral convexity, tentorium
• interhemispheric fissure
• Concave inner margin
• Older patient falls
• Pediatric patient shaken baby/child abuse

59
SUBDURAL HEMATOMA (ACUTE)
(CHRONIC)
60
CT HEAD TRAUMA
AIR IN FRONTAL SINUS
FRONTAL LOBE CONTUSION
TRAUMATIC PNEUMOCEPHALUS
NORMAL CHORIOD PLEXUS CALCIFICATIONS
61
EPIDURAL HEMATOMA
Biconvex elliptical fluid collection
62
EPIDURAL HEMATOMA
FRACTURE
Cause laceration of meningeal artery/vein
adjacent to inner table.
63
WHO ARE THE PATIENTS?

• CERVICAL SPINE INJURY

64
FOUR LINES FOR ALIGNMENT
65
C2 FRACTURE
66
COMPLEX FRACTURE DISLOCATION OF CERVICAL SPINE
CT scan
67
WHO ARE THE PATIENTS?

• CNS INFECTION

68
MAXILLARY SINUSITIS
ETHMOID SINUSITIS
69
SINUSITIS AND EPIDURAL ABSCESS
70
(No Transcript)
71
HIV AND TOXOPLASMOSISring enhancing lesions on CT
72
WHO ARE THE PATIENTS?

• CNS MALIGNANCY
• Metastatic disease more common than primary
  malignancy

73
CEREBELLAR METASTATICDISEASE
CT WITH CONTRAST
CT WITHOUT CONTRAST
74
T1- SCAN WITHOUT GADOLINIUM
T1 SCAN WITH GADOLINIUM
T2- SCAN
MR
T2
75

• MENINGIOMA

76
WHO ARE THE PATIENTS?

• VISUAL SYMPTOMS
• BITEMPORAL HEMIANOPSIA
• PITUITARY LESIONS

77
SKULL
MR- BRAIN
SELLA
NORMAL PITUITARY

78
PITUITARY ADENOMA
NORMAL
79
T1- MR
WITH GADOLINIUM
80
WHO ARE THE PATIENTS?

• DIZZINESS
• HEARING LOSS

81
ACOUSTIC NEUROMA
MR T1 weighted
WITHOUT GADOLINIUM
WITH GADOLINIUM
82
WHO ARE THE PATIENTS?

• CHRONIC NEUROLOGIC SYMPTOMS
• Dementia
• Demyelinating disease

83
NORMAL
ATROPHY
84
ABNORMAL WATER SIGNAL IN THE CEREBRAL WHITE MATTER
NORMAL
DUE TO DEMYELINAZATION ? MULTIPLE SCLEROSIS
85
M-3 LIFE BOAT
FROM OUR WEB PAGE
TO THE MR NEURO LABELED ANATOMY 1-
Click on M1 2- Click on Neuroanatomy MR
Sectional labeled
Anatomy
TO THE UVA NEURO SITE 1-Click on
Online Interactive Radiology Tutorial 2-Click on
Introduction to Head CT tab
TO eRADIOLOGY 1- Click on eRadiology 2-
Click on Interactive Tutorials in Radiology 3-
Find Head Neck Section 4- Click on Lesion
Localizer (Under Head Neck section)