Tumors and vascular diseases of the brain
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MRI is more sensitive, it can age strokes and can detect an acute stroke within thirty minutes. ... Lack of blood flow to the brain affects deep grey matter structures and can ...

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Jennifer Villa Frabizzio, M.D.

  • Abington Memorial Hospital

  • Radiology Group of Abington, PC

  • Board Certified in Diagnostic Imaging with Added Qualifications in Neuroradiology


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Topics for Discussion

Neuroimaging

Then and Now

Neuroanatomy

Vascular and Nonvascular

Vascular Disorders

Diagnosis and Treatment

Tumors

Primary and Metastatic Disease


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Neuroimaging- Then

Standard Radiograph

Pneumoencephalography

Direct Cerebral Angiography


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Pneumoencephalograhy

  • Introduced in 1919 by American Surgeon Dandy Walker

  • Primary method of Neurodiagnosis used late until late 1970’s early 1980’s

  • Lumbar puncture performed in sitting position

  • Patient placed in somersault chair with head suspended in harness

  • CSF removed and 10-15 mls of air introduced

  • Patient is tilted upside down and 50-60 mls more air introduced


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Pneumonecephalography cont.

Air outlined brainstem structures and supra tentorial structures to diagnose masses, tumors and cerebral atrophy

Very time consuming, could take from one to two hours to perform

Following the procedure patients invariably developed severe headache and maybe a fever

Sampling of CSF post procedure showed high protein and white blood cells, which seemed to be a response to the air

Symptoms would usually resolve within 48hrs


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Direct Cerebral Arteriography

  • Pioneered in 1927 by Dr. Egas Moniz

  • Needle was inserted directly into the common carotid artery in the neck and contrast material injected

  • Rapid series of radiographs were taken of the skull in numerous projections

  • Currently studies are preformed by inserting a catheter into the femoral artery

  • Remains as gold standard for imaging arterial and venous structures


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Neuroimaging-Now

  • Computed Axial Tomography

    • CAT SCAN

  • Magnetic Resonance Imaging

    • MRI


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Computed Tomography

  • From Greek tomos (slice) and graphein (to write)

  • Generation of three dimensional images for a series of two dimension Xrays taken around a single axis of rotation

  • Computer generated images produce an axial image

  • Early CT scans in early 1970’s had single slice, allowing imaging of the brain in four minutes

  • Modern state of the art scanners can have up to 200 slices and can image the whole body in 30 seconds

  • Iodine base contrast material in injected in an arm vein to optimize visualization of vessels and solid organs

  • Uses ionizing radiation to obtain images, and should be used with caution in pregnant or pediatric patients


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CT cont.

  • Advanced techniques

    CT angiography and venography

    • Contrast rapidly injected into an arm vein and timed to visualize arteries and veins

    • Has become first line minimally invasive procedure to image the intracerebral vasculature and coronary arteries

  • CT perfusion

    • Rapid imaging of the brain after contrast injection followed by computer post processing can generated area in the brain at risk for stroke


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Magnetic Resonance Imaging (MRI)

Powerful magnetic field used to align hydrogen atoms in the body

Radiowaves are activated that alter the alignment of this magnetization, allow for the atoms to relax at different rates according to their chemical composition

These signals are manipulated to reconstruct images of the body

Greater soft tissue contrast than CT

No ionizing radiation

Must be extremely careful to remove all metal from patients

Contraindicated in patients with pacemakers


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MRI cont.

  • Advanced techniques

    • MR Angiography

      detection of moving molecules done without the injection of contrast to visualize flowing blood

      excellent to visualize head and neck vessels

    • Gadolinium based contrast agent is injected into an arm vein, mixed with flowing blood and allows for visualization of vessels especially in the chest and abdomen


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MRI cont.

  • Diffusion imaging

    • For visualization of acute stroke, damaged cells swell and cause restricted diffusion

  • MR spectroscopy

    • Separating the chemical composition of brain lesions into different peaks to determine chemical composition

  • Functional MRI

    • Using changes in blood flow to monitor neural activity


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Neuroimaging

Nonvascular


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Neuroimaging

Vascular


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Vascular diseases

Stroke

Trauma/Intracranial Hemorrhage

Aneurysm

Arteriovenous Malformations


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Stroke

  • Acute episode leading to a neurologic deficit

    • 80% are due to ischemia (either thrombotic or embolic)

    • 20% other

  • Transient ischemic attack (TIA)

    • Focal events that resolve in 24hrs


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Stroke cont.

  • Of the 80%, three quarters are due to atherosclerotic disease or occlusion of vessels.

  • Diagnosis can be made by both CT and MRI, as well as the advanced images techniques

    • MRI is more sensitive, it can age strokes and can detect an acute stroke within thirty minutes.

    • CAT scan can detect a stroke within 6 hrs, and is useful to determine if there is underlying hemorrhage


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71 year old white female

Found by husband in the bathroom on the floor, unable to move left side of her body

Brought by EMS to AMH and had a CAT scan


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Cont.

  • Admitted to intensive care

  • CAT scan performed 6 hrs later after worsening of symptoms


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Cont.

  • Patient continues to deteriorate, despite supportive measures

  • CAT scan performed 24 hrs after admission


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  • No improvement

  • CAT scan performed 12 hrs later, 48 hrs after admission


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19 year old white male

Found unconscious in dorm room by roommate after drinking all night at a fraternity party

Friends had seen him take some pills, found later to be valium (benzodiazepine-tranquilizer)


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Anoxic brain injury

  • Lack of blood flow to the brain affects deep grey matter structures and can cause irreversible damage

  • Can also be seen in near drowning, carbon monoxide poisoning


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Intracranial Hemorrhage

  • Non Traumatic

    • Hypertension (most common)

    • Tumor

    • other

  • Traumatic

    • Epidural and subdural Hematomas

    • Hemorrhagic contusions


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Hemorrhage cont.

  • Hypertensive type most common in small arteries off of the middle cerebral artery

  • High mortality depending on size and location


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81 year old black male

  • Found at breakfast with difficulty speaking

  • Brought to AMH by son

  • Ran out of blood pressure medicine last week

  • Vital signs in ER

  • Blood pressure 210/80

  • CAT scan upon arrival


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Cont.

  • ICU Staff was unable to control blood pressure, symptoms worsened


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Hemorrhage cont.

  • Traumatic

    • Subdural hematomas

      • Common in the elderly or in children due to child abuse

      • Tearing of bridging veins along the edge of the brain

      • Can grow large and may need neurosurgical evacuation


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Hemorrhage cont.

  • Epidural hematoma

    • Mostly due to injury to the middle meningeal artery, superficial vessel that runs along the skull

    • Commonly associated with skull fractures

    • Large ones are neurosurgical emergencies


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Aneurysms

Most common type is the berry or saccular aneurysm

Are usually congenital or degenerative

Focal outpouching of a artery

Occur in specific locations along the Circle of Willis

Once diagnosed, the risk of rupture is 1.3% per year

A ruptured aneurysm requires urgent diagnosis and treatment, due to a high risk of rebleeding and 50% mortality


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Aneurysms cont.

  • Patients present with “worst headache of life” and can have varying stages of consciousness

  • CAT scan of the brain show diffuse subarachoid hemorrhage, “crab of death”


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Aneurysms cont.

  • Treatment

  • Conventional-crainiotomy and aneurysm clipping

  • Neurointerventional-intravascular coiling


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Arteriovenous Malformations (AVM)

  • Network of arteries connected directly to veins with no intervening brain tissue or capillaries

  • Can hemorrhage because of high flow state

  • Treatment

    • Endovascular coiling

    • Glue

    • Stereotactic Radiosurgery


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58 year old female

  • MVA, crashed car into a tree because she “blacked out”

  • Arrives at AMH with headache, bruising but awake

  • CAT scan performed


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Brain Tumors

  • Primary brain tumors are 70% of all intracranial neoplasms

  • The remaining 30% represent metastases from primary tumors elsewhere in the body, common ones include lung and breast cancer

  • MRI with Gadolinium in the modality of choice for diagnosis


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Brain tumors cont.

  • Primary Brain Tumors

    • 80% are gliomas, the most aggressive is the Gliomblastoma Multiforme (GBM)

    • 20% are all others, which include meningiomas from the brain surface, nerve sheath tumors and lymphoma

    • Treatment is a combination of surgery, radiation and chemotherapy




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