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NEURO IMAGING. Dr. Francis Neuffer Department of Radiology USC - SOM. GOALS AND OBJECTIVES. Review major imaging modalities of neuro imaging . CT, MR, Ultrasound , Angiography Review classic disease states of vascular, traumatic , infectious and neoplastic diseases .

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slide1

NEURO IMAGING

Dr. Francis Neuffer

Department of Radiology

USC-SOM

slide2

GOALS AND OBJECTIVES

  • Reviewmajorimagingmodalities of neuroimaging.

CT, MR, Ultrasound, Angiography

  • Reviewclassicdiseasestates of vascular, traumatic, infectious

and neoplasticdiseases.

slide3

DIGITAL SCOUT FILM SHOWING BEGINNING AND END OF CT SCAN.

Multiple sectional images are obtained from a preliminary

scout image showing the beginning and end of the scan.

slide4

iV Contrast enhancement-CT

NON-CONTRAST

STUDY

IV IODINE CONTRAST

STUDY

anatomy
ANATOMY

Selected images from CT scans posterior fossa level

Basilar

Artery

Supracellar

Cistern

Temporal

Horn lateral

ventricle

Pons

4th

Ventricle

Cerebellum

anatomy thalamic level
ANATOMYThalamic level

3rd

ventricle

Atria

Lateral

Ventricle

Sylvian

fissure

Thalamus

Falx cerebri

anatomy internal capsule level
ANATOMYInternal capsule level

Anterior Horn

Lateral ventricle

Caudate Nucleus

Internal

capsule

Lentiform

nucleus

Occipital

Lobe

anatomy ventricle level
ANATOMYVentricle level

Anterior Horn

Lateral ventricle

Posteror

Horn Lateral

ventricle

anatomy lateral ventricle level
ANATOMYLateral ventricle level

Frontal

lobe

Body lateral

ventricle

Parietal

lobe

Occipital

lobe

Falx cerebri

anatomy supraventricular level
ANATOMYSupraventricular level

Gyrus

Centrum

Semiovale

Sulcus

Superior

Sagittal Sinus

magnetic resonance
MAGNETIC RESONANCE

Hydrogen protons align in magnetic field

Radio frequency(RF)

excitation and

transmission

No ionizing radiation

t1 scan
T1 SCAN

MR SIGNAL

T2 SCAN

SCANS ARE DESIGNED TO SHOW SPECIFIC TISSUE

AND SPECIFIC PATHOLOGY

slide13

VARIOUS MRI SEQUENCES

Thetissuesignalvariesdependingonthetype of scanperformed.

T1

T2 (CSF/edema)

FLAIR (edema)

Diffusion

slide14

NORMAL

CEREBRAL ARTERIOGRAM

NORMAL

ULTRASOUND

Flow is seen at the common carotid bifurcation on contrast

X- ray arteriography and B-mode ultrasound.

slide15

CAROTID ARTERY

Color Doppler

The vessel lumen can be imaged with ultrasound and the velocity of the flow can be measured.

A stenotic lesion will show acceleration of flow through the narrowed lumen.

catheter injection of rt common carotid artery
Catheter injection of RT common carotid artery
  • CCA common carotid A.
  • ICA internal carotid A.
  • ECA external carotid A.
  • MCA middle cerebral A.
  • ACA anterior cerebral A.

ACA

MCA

ECA

ICA

CCA

slide17

VASCULAR ANATOMY

Images of vessels at the Circle of Willis

ACA

MCA

mr vascular anatomy
MR VASCULAR ANATOMY

Anterior cerebral

Middle

cerebral

Basilar

artery

ECA

ACA

MCA

Carotid

bulb

ICA

Vertebral

artery

CCA

ICA

MR Angiogram- venous injection

Images can be obtained at MR by injecting gadolinium and imaging rapidly as the agent circulates through the arterial circuit.

who are the patients
WHO ARE THE PATIENTS ?
  • VASCULAR ISCHEMIA
  • TRAUMA
  • INFECTIOUS WORKUP
  • MALIGNANCY WORKUP
ct scanning as initial sorting
CT SCANNINGas initial sorting
  • Ischemia
    • Global
    • Focal

Hemorrhage

    • Hypertensive hemorrhage
    • Amyloid angiopathy
    • Hemorrhagic infarction
    • Subarachnoid hemorhage
slide21

FOCAL DEFICIT OF 24 HRS

  • ACUTE CVA
  • 85% ISCHEMIC
  • 15% HEMORRAGHIC
  • TREATMENT DIFFERENCE
  • ANTICOAGULATION FOR ISCHEMIC CVA
slide22

STENOSIS

NORMAL

slide23

CT OF ISCHEMIC STROKE

1 DAY POST

2 DAY POST

Note increase in edema

lacunar infarct
LACUNAR INFARCT
  • Small vessel = lenticulostriatevessel
  • MCA proximal branch
  • basal ganglia-thalamic
vascular distributions
VASCULAR DISTRIBUTIONS

Anterior Cerebral Artery

Middle Cerebral Artery

Posterior Cerebral Artery

The different vascular distributions of cerebral territories are

represented on color coded CT diagrams

ct scanning as initial sorting1
CT SCANNINGas initial sorting

Hemorrhage

  • Hypertensive hemorrhage
  • Amyloid angiopathy
  • Hemorrhagic infarction
  • Subarachnoid hemorhage
slide27

SUBARACHNOID

HEMORHAGE

Increased density

Normal

The supra sellar cisterniswhiteduetothebloodmixedwiththe CSF.

subarachnoid hemorrhage
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.

slide29

CAROTID ANEURYSM

Associated with Polycystic Renal disease

And Marfans Syndrome

Aneurysms are often at

vascular branch points and

show relative deficit of media

there which contributes to

vessel wall weakness

intracerebral hemorhage hypertensive events
INTRACEREBRAL HEMORHAGEHYPERTENSIVE EVENTS

Acute Blood is dense on

Non contrast CT

Pontine Hemorrhage

Thalamic Hemorrhage

slide31

CEREBRAL AMYLOID ANGIOPATHY

(CAA)

IS AN IMPORTANT CAUSE OF SPONTANEOUS CORTICAL- SUBCORTICAL INTRACRANIAL HEMORRHAGE (ICH) IN THE NORMOTENSIVE ELDERLY.

Chao C P et al. Radiographics 2006;26:1517-1531

slide32

Hemorragic infarction—delayed several days

Withreperfusiononinfarctareathereishemorrhageintoinfarctzonewith local masseffect and midlineshift.

ct scanning as initial sorting2
CT SCANNINGas initial sorting
  • Ischemia

Hemorrhage

    • Hypertensive hemorrhage
    • Amyloid angiopathy
    • Hemorrhagic infarction
    • Subarachnoid hemorhage
comparison of infarct zone and ischemic zone to identify treatment candidates
Comparison of infarct zone and ischemic zoneto identify treatment candidates

GOAL FOR IMAGING

stroke intervention
STROKE INTERVENTION

Thrombolytic therapy to salvage ischemic brain at the border of the infarct zone (ischemic penumbra).

Who benefits and how to select?

stroke intervention1
Thrombolytic therapy

3-6 hour window

Risk of hemorrhagic conversion

STROKE INTERVENTION

Typically 3hrs sinceonsetisthelimitforinitiation of venousthrombolytictherapy. With arterial therapythewindow of action can be extended . Therisk of bleedingintotheinfarctzonewithreperfusionis a complicationthat can worsen prognosis.

slide37

Lt

Rt

Note acute occlusion of Rt. MCA circulation and edema in Rt. hemisphere on CT. Comparison of the normal Lt. side is shown.

slide38

catheter

Catheter is advanced for thrombolysis of the MCA thrombus with improved perfusion on last injection of contrast.

ct vs mr
CT vs. MR

?Abnormality on CT

Questionable lesion on CT in a Rt. periventricular location.

slide40

Compared to CT--MR scans with T1, T2, and

diffusion weighted better show

the acute evolving ischemic infarction

T1

T2

Diffusion

mr vs ct in early cva
MR vs. CTIN EARLY CVA
  • MR LIMITATIONS
  • COMPLEX MR SIGNAL OF HEMORRHAGE
  • RELATED TO HEMAGLOBIN—Fe EFFECTS
  • UNSTABLE PATIENT-PATIENT MOTION
  • MORE A PROBLEM IN MR (LONGER SCAN TIME)
  • CT READILY VISUALIZES BLOOD PRODUCTS
  • ACCESS- CT IS AVAILABLE FOR ER PATIENTS
ct scanning as initial sorting3
CT SCANNINGas initial sorting
  • Ischemia
    • Global
    • Focal

Hemorrhage

    • Hypertensive hemorrhage
    • Amyloid angiopathy
    • Hemorrhagic infarction
    • Subarachnoid hemorhage
subdural hematoma
SUBDURAL HEMATOMA

Venous bleeding from “bridging veins” which connect cerebral cortex to Dural sinuses

Concave inner margin

Older patient –atrophy enlarged subdural space

unstable gait–falls

Pediatric patient –shaken baby/child abuse

small subdural space can lead to herniation

slide45

SUBDURAL HEMATOMA

(ACUTE)

Over time thebloodbreaksdown and decreases in density.

slide46

SUBDURAL HEMATOMA

Hit head on RT. With superficial scalp hematoma

Subdural hematoma on LT due to tearing of bridging veins with

Deceleration with fall.

slide47

EPIDURAL

HEMATOMA

FRACTURE

Cause: laceration of meningeal artery/vein adjacent to inner table.

Lucid interval post trauma –later cns injury due to mass effect

Epidural hematomas are more focal than subdurals since

the blood is more confined by the periosteum of the skull.

slide49

SKULL BASE

FRACTURE

Can lead to cerebral spinal fluid leak and risk of meningitis

The purple ecchymosis behind the ear is called Battle sign described as a clinical finding

slide50

“RACCOON EYES”

Periorbital ecchymosis is another sign of a basal skull fracture. Blood tracks along the periosteum and can collect in soft tissues of the orbital lid.

CSF rhinorhea can occur with fractures extending through cribriform plate

ct head trauma
CT HEAD TRAUMA

AIR IN FRONTAL SINUS

FRONTAL LOBE CONTUSION

TRAUMATIC PNEUMOCEPHALUS

NORMAL CHORIOD PLEXUS

CALCIFICATIONS

Air extends intracranially from fracture of the skull or through the sinuses.

intracerbral pressure herniation
INTRACERBRAL PRESSUREHERNIATION
  • Tonsillar - brainstem - cardiopulmonary arrest.
  • Falcine - anterior cingulate gyrus –ACA infarct.
  • Uncus- temporal lobe-- 3rd nerve
meningitis bacterial viral
MENINGITISbacterial / viral
  • Little role for imaging-can delay treatment
  • Lumbar puncture and gram stain
  • Meningococcal Bacterial can be fatal
  • Headache, Stiff neck, Fever, Photophobia
slide55

SINUSITIS

AND

EPIDURAL ABSCESS

Spread of sinus infection to the epidural space can occur.

aids patients
AIDS PATIENTS
  • TOXOPLASMOSIS --ring enhancing lesions
  • Atrophy -- HIV viral effect
  • PML -- progressive multifocal leukodystrophy

JC virus reactivated-fatal-rapid

hiv and toxoplasmosis ring enhancing lesions on ct
HIV AND TOXOPLASMOSISring enhancinglesionson CT

noncontrast

contrast

Patients with altered immunity are subject to many atypical infections.

Toxoplasmosis is rarely seen in immunocompetent patients.

who are the patients3
WHO ARE THE PATIENTS?

CNS MALIGNANCY

Metastatic disease- 50/50 -Primary malignancy

tumors
TUMORS
  • Primary = Metastatic
  • Lung, Breast, Renal
  • Adult- Supratentorial primary tumors
  • Pediatric- Infratentorial primary tumors
metastatic lesions history multiple enhance with contrast
METASTATIC LESIONSHISTORY / MULTIPLEenhance with contrast

The ring enhancing lesion is the site of abnormal blood/brain barrier.

The low density center often is necrotic tissue.

CT WITH CONTRAST

adults glioblastoma multiforme
ADULTSGlioblastomaMultiforme
  • Malignant astrocytoma-supratentorial
  • Can cross midline -corpus callosum
  • Butterfly

Coronal section

slide62
GBM

Axial section MR

with gadolineum contrast

slide63
MENINGIOMA-benign

DURAL BASED LESIONS

CAN BE LARGE.

INCREASED DENSITY is due to calcium and not bleeding

tumors1
TUMORS
  • Pediatric- Infratentorial primary tumors
pilocystic astrocytoma
PILOCYSTIC ASTROCYTOMA
  • Pediatric
  • Benign
  • Cystic with nodule
  • Posterior fossa
  • Cerebellum
medulloblastoma
MEDULLOBLASTOMA
  • Pediatric-malignant-PNET
  • Post fossa -cerebellum
  • Spread via CSF
who are the patients4
WHO ARE THE PATIENTS?

VISUAL SYMPTOMS

Bitemporal hemianopsia

PITUITARY LESIONS-

impinge on optic chiasm

slide68

SKULL

MR- BRAIN

SELLA

NORMAL PITUITARY

craniopharyngioma
CRANIOPHARYNGIOMA
  • Rathke’s pouch - grow from mouth to between anterior and posterior pituitary
  • Bitemporalhemianopsia
  • Pediatric patient
  • Calcify-Benign
who are the patients5
WHO ARE THE PATIENTS?

HEARING LOSS

Conduction vs sensory

Weber and Rinne test

slide72

SCHWANNOMA

INTERNAL AUDITORY MEATUS LESION

MR SCANS

WITH GADOLINIUM

WITHOUT GADOLINIUM

Bilateral lesions associated with Neurofibromatosis 2.

who are the patients6
WHO ARE THE PATIENTS?

CHRONIC NEUROLOGIC SYMPTOMS

DEMENTIA

Alzheimers, Multi infarct, Hydrocephalus

slide74

NORMAL

ATROPHY

With Alzheimer’s disease little is seen on MR and CT except atrophy as a nonspecific finding.

slide75

Coronal scans

NORMAL PRESSURE HYDROCEPHALUS

Dllated ventricles

NORMAL

NPH

normal pressure hydrocephalus
NORMAL PRESSURE HYDROCEPHALUS
  • CSF not absorbed by arachnoid granulations
  • Ventricles dilate
  • Stretch fibers around ventricles - corona radiata
  • Incontinence, Gate disturbance and Dementia
  • LP/Shunt improves symptoms
who are the patients7
WHO ARE THE PATIENTS?

CHRONIC NEUROLOGIC SYMPTOMS

DEMYELINATING DISEASE

slide78

ABNORMAL WATER SIGNAL IN THE CEREBRAL WHITE MATTER

NORMAL

DUE TO DEMYELINAZATION

? MULTIPLE SCLEROSIS

Focal white matter lesions show increased water due to breakdown on myelin at sites of involvement.

demylination multiple sclerosis
DEMYLINATIONMULTIPLE SCLEROSIS
  • Autoimmune- northern latitudes
  • Young adult- female-
  • Blurred vision –optic nerve
  • Internuclear ophthalmoplegia - CN 3 and 6
  • Sensory deficit
  • Autonomic dysfunction- bladder/bowel
slide80
IF YOU FEEL LOST

THERE’S STILL HOPE

slide81

CT -acute hemorrhage

MR- chronic

Ultrasound- vascular screening

Angiography- intervention