CD B [RADIO]: INTRO TO NEURO IMAGING MODALITIES

APRIL 12, 2018

CRANIAL CT SCAN THE “STAR”

 2nd basic slice
 Area of the suprasellar cistern

 In order to perform a head CT, the patient is placed on the CT table

in a supine position and the tube rotates around the patient in the
gantry.
 In order to prevent unnecessary irradiation of the orbits and
especially the lenses
 Head CTs are performed at an angle parallel to the base of the skull.
 Slice thickness may vary, but in general, it is between 5 and 10 mm
for a routine Head CT.
 Intravenous contrast is not routinely used, but may be useful for
evaluation of tumors, cerebral infections, and in some cases for the MR. HAPPY
evaluation of stroke patients.  3rd basic slice
 Area of the quadrigeminal cistern (symmetrical smile)
6 ESSENTIAL CT IMAGES

THE “X”
 1st basic slice taken near the base of the skull.
MR. SAD
 4th basic slice

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CD B: RADIO | INTRO TO NEURO IMAGING MODALITIES
APRIL 12, 2018

LOOKING AT THE BRAIN

MIDLINE
THE WORMS
 The middle of the brain should be in the middle of the head and the
 5th basic slice two sides of the brain should look alike
 Any shift of midline structures is presumed to represent a mass
lesion on the contralateral side

 Symmetry
 Sulcal pattern should be symmetric
 Loss of sulci may result from compression (mass, edema)
 Medial displacement of the sulci may represent compression
resulting from an extracerebral fluid collection (subdural or
epidural hematoma)

THE COFFEE BEAN  Midline structures

 6th basic slice  Sella and suprasellar region:
 Pineal region:
 Craniocervical junction:
 Anterior arch of C1, odontoid process, cervical occipital
ligaments anteriorly
 Foramen magnum, cerebellar tonsils, obex

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TYPES OF HERNIATION TONSILLAR HERNIATION

 Subfalcial (cingulate) herniation  Is a type of cerebral herniation characterized by the inferior descent
 Caused by focal, ipsilateral space occupying lesions, ie., tumor of the cerebellar tonsils below the foramen magnum.
or axial or extra-axial hemorrhage
 Uncal herniation
 Caused by focal, ipsilateral space occupying lesions, ie., tumor
or axial or extra-axial hemorrhage
 Downward (central, transtentorial) herniation
 External herniation
 Tonsillar herniation
 Caused by focal, ipsilateral space occupying lesions, ie., tumor
or axial or extra-axial hemorrhage

BASAL CISTERNS
QUADRIGEMINAL CISTERN
 Axial plane: symmetric smile

SUBFALCINE HERNIATION
 Most common cerebral herniation pattern, is characterized by
displacement of the brain beneath the free edge of the falx
cerebri due to raised intracranial pressure.

 Asymmetry may represent rotation of the brain stem due to

transtentorial herniation

UNCAL HERNIATION
 Downward brain herniation, usually related to cerebral mass effect
increasing the intracranial pressure.
 Mass effect and obliteration of the suprasellar cistern will be seen.
 The midbrain is displaced and effaced.

 Effacement: cerebellar or brainstem mass

 Opacification: subarachnoid hemorrhage

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SUPRASELLAR CISTERN
 Pentagon or the Jewish star
 Five corners of the pentagon
 Interhemispheric fissure anteriorly
 Sylvian cisterns anterolaterally
 Ambient cisterns posterolaterally
 Interpeduncular fossa posteriorly

3RD VENTRICLE

 Significant asymmetry: uncal herniation

LATERAL VENTRICLES

 Central mass: sellar or suprasellar tumor

 Opacification: subarachnoid hemorrhage or meningitis

EMERGENCY CT CHECKLIST
 Is the middle of the brain in the middle of the head?
 Do the two sides of the brain look alike?
 Can you see the smile and the pentagon or Jewish star?
 Is the fourth ventricle in the midline and more or less symmetrical?
VENTRICLE  Are the lateral ventricles huge, with effaced sulci?
 Overall size of the ventricular system is assessed
 Enlargement of the lateral ventricles and third ventricle in the setting NEUROIMAGING OPTIONS
of headache, or with signs of intracranial mass, may represent  Radiography/X-ray
hydrocephalus  CT SCAN
 MRI
4TH VENTRICLE  Ultrasound
 Angiography
 Fourth ventricle in the posterior fossa, because it is the hardest to
see on CT scanning
 Asymmetry or shift of the fourth ventricle may be the only sign of
significant intracranial masses

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RADIOGRAPHY/X-RAY
 In a patient with suspected neurologic pathology conventional
radiography is virtually useless in patient management
 What modality do we request for?
 Non-contrast or with contrast?
ULTRASOUND
 May be used as the first test in infants
 Used almost exclusively in babies because their fontanelle provides
an "acoustic window"
 Transcranial techniques for evaluation of the intracranial vessels.
 For the evaluation of the carotid arteries.
MRI or CT?
 General rule, CT is performed for acute neurologic illness and
MR for the more chronic and subacute cases
 If onset is within 24 to 48 hours, start with CT
 If problem is more than 2 days, start with an MR
 If patient is too sick (e.g. multisystem trauma, those who
require assisted ventilation) MR might be difficult to perform
CONTRAST OR NON-CONTRAST?
 If initial imaging suggests a tumor, give contrast
 Do not use intravenous contrast agent in acute setting unless brain
abscess or tumor is being considered
 Give gadolinium in MR if clinical findings suggest a specific
neurologic localization, a seizure or a strong history of cancer or
infectious disease
PLAIN CT VS CONTRAST CT
DIFFUSION-WEIGHTED IMAGING (DWI) IN ACUTE CEREBRAL
ISCHEMIA:
 Greatly enhances the ability of MRI to diagnose early cerebral infarct
accurately
 Phenomenon of diffusion, related to Brownian motion at molecular
level
 Intracellular water molecules are much more limited in movement
than extracellular water
 The more restricted the water movement, the brighter it will
appear on DWI images
 Stroke: ischemic areas tend to swell  there is osmosis of free water
into the dying cells  more restricted movement  bright on DWI
 DWI changes in acute cerebral infarction precedes those seen in T2
weighted and FLAIR
ANGIOGRAM?
 If initial imaging suggests a vascular lesion; do a catheter
angiogram, CT (CTA) or MR angiogram (MRA)
 MRA is best for screening of arteriovenous malformations
(AVM)
 CTA is best for problem solving and aneurysm treatment
planning
 Angiography is generally reserved for endovascular treatment
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 Cerebral angiography uses a catheter, x-ray imaging guidance and
an injection of contrast material to examine blood vessels in the
brain for abnormalities such as aneurysms and disease such as
atherosclerosis (plaque).
 If seizure disorder is chronic, especially those refractory to therapy,
MR is preferred
INFECTION AND CANCER
 Contrast-enhanced MR is the preferred study
 Meningeal disease is better depicted in MR
 Parenchymal tumor or metastatic disease will be demonstrated with
this study, and contrast-enhanced MR has the advantage of
depicting meningeal disease much better than any other imaging
modality

HEADACHE
 Frequent indication for brain imaging
IMAGING STRATEGY FOR COMMON CLINICAL SYNDROMES  Acute severe headache
 Acute Trauma  Plain CT scan
 Stroke  “thunderclap” headache – may be due to subarachnoid
 Seizure hemorrhage
 Infection and cancer  May be the result of acute hydrocephalus, enlarging
 Headache intracranial mass
 Chronic headache
Clinical Plain CT CT with Plain MRI MRI with  Generally evaluated by MR
presentation contrast contrast  If no associated focal neurologic deficit – plain MRI
Trauma XX  If presenting complaint is solely headache, the yield of
Stroke XX XX imaging is low
Seizure X X X XX  If with accompanying focal neurologic deficit – MRI with
Infection X X X XX contrast
Cancer X X X XX  Typical uncomplicated migraine may not require imaging
Acute XX
headache HEAD TRAUMA
Chronic XX IMAGING
headache
SKULL X-RAY

ACUTE TRAUMA  Not sensitive for detection of intracranial pathology

 Plain CT scan is preferred because it can be obtained quickly and on  Standard views: APL (anteroposterior and lateral)
practically any patient  Others: Caldwell, Waters, Submentovertex
 CT scan machines are more widely available  The absence of skull fractures on conventional radiography does not
 Most important abnormality to be detected are extracerebral exclude significant intracranial injury
hematomas
CT SCAN
STROKE  Quick, widely available
 Plain CT scan is preferred initial imaging modality  Accurate in detection of acute intra and extra-axial hemorrhage
 In acute phase of bland infarcts, CT scan is normal or nearly normal.  Accurate in detection of skull, facial and orbital fractures
But we request for CT scan to search for evidence of hemorrhage in
these patients.
 The absence of hemorrhage in patients with bland infarct
allows performance of anticoagulation or thrombolytic therapy
 Subarachnoid hemorrhage requires further work-up by MRA or CTA
to search for vascular malformations

SEIZURE
 If 1st seizure, an intracranial tumor, infection or other acute process
must be excluded
 CT or MR with contrast are preferred
 If in the immediate post-ictal state or if a residual neurologic deficit
is present, plain CT scan should be the first imaging study

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PRIMARY LESIONS
 Occur as direct result of a blow to the head.
 Extra-axial: bleeding that occurs within the skull but outside
of the brain tissue.
 Epidural hematoma
 Subdural hematoma
 Subarachnoid hemorrhage
 Intraventricular hemorrhage
 Intra-axial: bleeding within the brain itself, or cerebral
Axial CT scan demonstrates a right parietal depressed skull
hemorrhage
fracture with overlying soft tissue swelling.
 Diffuse axonal injury (DAI)
A, The fracture is well seen when a wide window is used to
 Cortical contusions
enhance contrast between bone and soft tissue.
 Intracerebral hematomas
B, The narrower window demonstrates excellent contrast
 Subcortical gray matter injury
between gray and white matter but fails to show the fracture. A
small extra-axial hematoma is seen in the right parietal area.
EXTRA-AXIAL BRAIN INJURY
EPIDURAL HEMATOMA:
MRI  Usually arterial in origin.
 Often result from skull fracture (85-95%) that disrupts the middle
 Traditionally less desirable than CT in acute setting because:
meningeal artery.
 Longer exam time
 May occur from stretching and tearing of meningeal arteries without
 Difficulty in managing life support and monitoring equipment
associated fractures
 Inferior bone detail
 Most are temporal or temporoparietal in location.
 Comparable or superior to CT in detection of acute epidural and
 Characteristics:
subdural hematoma and non-hemorrhagic brain injury
 Extraaxial collections
 Modality of choice for subacute and chronic head injury and in
 Overlying skull fracture
patients with acute head trauma with neurologic findings
 Does not cross sutures
unexplained by CT
 Lenticular or biconvex
 Can cross the falx
 CT:
 Acute: well-defined high attenuation lenticular or biconvex
extraaxial collections
 Mass effect with sulcal effacement and midline shift
 Overlying skull fracture
 Does not cross sutures but can cross the falx

HEAD INJURY CLASSIFICATION

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SUBDURAL HEMATOMA
 Typically venous in origin
 Stretching and tearing of cortical veins in the subdural space
 Also due to disruption of penetrating branches of the
superficial cerebral arteries
 Commonly seen after acute deceleration injury from a motor
vehicle accident or fall
 Extends over a much larger space than in epidural hematoma
because the inner dural layer and arachnoid are not firmly attached
as the dura and the inner table of the skull
 Characteristics:
 Extraaxial collection
 Subdural hematoma with hematocrit effect
 Can cross sutural margins
 Sediment level or “hematocrit level”
 Crescentric
 Upper layer has low attenuation representing old blood
 Extends over much larger space
 Lower layer has high attenuation representing fresh blood
 Does not cross the falx cerebri and tentorium
 Seen in re-bleeding patients or patients with clotting disorders
 Acute subdural hematoma
 Crescentric
 Crescentric, high attenuation
 Can cross sutural margins
 Most are supratentorial
 Does not cross the falx cerebri and tentorium

EPIDURAL VS SUBDURAL HEMATOMA

 Subacute subdural hematoma

 Between several days to 3 weeks after the acute event.
 Chronic subdural hematoma
 Low attenuation value similar to CSF
 Crescentric
 Mass effect with midline shift

 The extradural haematoma because of the restriction by the

meninges is shaped like a half lemon as depicted by the picture
of the lemon on the right side while the subdural haematoma
without restriction by the meninges, then to spread out over the
surface of the cerebrum and is shaped like a banana as shown
by the banana depicted on the left.

SUBARACHNOID HEMORRHAGE:
 Disruption of small subarachnoid vessels or direct extension into the
subarachnoid space by contusion or hematoma
 May be due to trauma or ruptured aneurysm
 CT:
 Linear areas of high attenuation within the cisterns and sulci

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INTRA-AXIAL HEAD INJURY

DIFFUSE AXONAL INJURY
 Widespread disruption of axons at the time of an acceleration/
deceleration injury (high speed motor vehicle crashes)
 Affected area of the brain may be distant from the site of direct
impact
 Usually not seen on imaging but better seen by MRI than CT
 Trauma will cause the axon to twist and tear causing permanent
death of brain cells
 Loss of consciousness starts immediately after injury and more
Where is the subarachnoid hemorrhage? severe than in patients with cortical contusions or hematoma
 CT:
 Subtle or absent findings
 Most common – small petechial hemorrhages at the gray-
white matter junction or corpus callosum
 Ill-defined areas of decreased attenuation may occasionally be
seen

 MRI:
 Isointense to T1W and T2W
 FLAIR
 More sensitive in detecting acute subarachnoid
hemorrhage
 High signal intensity

 MR:
 Small foci of increased signal within the white matter, multiple
as many as 15-20 lesions in severe head injury
 T2-weighted MR:
 Several adjacent foci of high signal, representing DAI in
the right frontal parasagittal white matter.

 If due to ruptured aneurysm, CT angiography should be done

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CORTICAL CONTUSION:
 Areas of focal brain injury primarily involving the superficial gray
matter
 Less likely to have loss of consciousness and with better prognosis
than in patients with diffuse axonal injury
 Common in patients with severe head trauma
 Well seen on CT
 Tend to be multiple and bilateral
 Occurs near bony protuberance
 Common sites:
 Temporal lobes above the petrous bone or posterior to CT scan: Findings????
the greater sphenoid wing
 Frontal lobes above the cribriform plate, planum
sphenoidale and lesser sphenoid wing
 Can also occur at the margins of depressed skull fractures

SECONDARY LESIONS
 Occur as a consequence of primary lesion
 Hemorrhagic lesions  Usually as a result of mass effect or vascular compromise
 Foci of higher attenuation within superficial gray matter  Often preventable
which may be surrounded by larger area of low  Includes:
attenuation secondary to edema  Cerebral swelling
 Brain herniation
 Hydrocephalus
 Ischemia or infarction
 CSF leak
 Leptomeningeal cyst
 Encephalomalacia.

LEPTOMENINGEAL CYSTS
 Also known as growing skull fractures
 Are an enlarging skull fracture that occurs near post-
traumatic encephalomalacia  volume loss
There is extensive bruising of the right side of the brain, showing up
 Ex-vacou dilatation of the ventricle
as a large, diffuse grey area. You can also see that there are patches
of white within the grey area. This represents bleeding. The grey area
represents swelling (edema)

 MR:
 Poorly marginated areas of increased signal on T2W in the
characteristic locations
 Hemorrhage – heterogeneous signal intensity that varies
depending on age of lesion

Source: PPT ONLY!!

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