IMAGING OF CENTRAL NERVOUS SYSTEM IMS STUDENTS 19.12.2014.ppt

imaging of central nervous system a radiology presentation

1. Imaging of
central nervous system
Dr. Praveenkumar P Choudri
MDRD, DNBRD
Consultant Radiologist.
BMJH.

3. Modalities
•Plain radiograph.
•Ultrasonography.
•CT scan.
•MRI scan.
•PET scan.
•DSA.

4. • Normal anatomy of sella.

5. SIGNS OF RAISED
INTRACRANIAL PRESSURE
•Increased vascular markings
•Widening of the sella turcica –J shaped
sella, “double floor” sella.
•Erosion of sella turcica.
•Gyri make prominent markings on the skull.
•Widening of sutures-in children.

6. J shaped sella

9. Tumoral calcification
• Intracranial calcifications.

10. Tumoral calcifications

11. Neuroradiologist
•A consultant in imaging and disease of the
brain, spinal cord, head, neck, face and
peripheral nerves

12. Neuroradiology
•Plain Film
•CT
•US
•MRI
•Interventional
–Angiography
–Myelography
–Biopsy
•Nuclear Medicine

13. Neuroradiology
•A request for an exam is a consultation
–History
–Pertinent physical exam findings
•Lab results
–Creatinine
–PT/INR
–What is the question?

14. CT Basics
•Computed tomography (CT)
•Computed axial tomography or computer –
assisted tomography (CAT)

15. CT Basics

16. CT History
SIR GODFREY N. HOUNSFIELD
•1979 Nobel Laureate
in Medicine

17. CT Terminology
•Attenuation
–Hyperattenuating (hyperdense)
–Hypoattenuating (hypodense)
–Isoattenuating (isodense)
•Attenuation is measured in Hounsfield units
–Scale -1000 to 1000
•-1000 is air
•0 is water
•1000 is cortical bone

18. CT Terminology
•What we can see
–The brain is grey
•White matter is usually dark grey (40)
•Grey matter is usually light grey (45)
•CSF is black (0)
•Things that are bright on CT
–Bone or calcification (>300)
–Contrast
–Hemorrhage (Acute ~ 70)
–Hypercellular masses
–Metallic foreign bodies

19. CT Terminology

20. CT Artifacts

21. Contrast
•Barium
•Iodinated
–vascular
–Biliary, Urinary
–CSF
•Gadolinium

22. Contrast
•Types of iodinated contrast
–Ionic
–Nonionic - standard of care
•No change in death rate from reaction but number of
reactions is decreased by factor of 4.
•If an enhanced study is needed, patient needs to
be NPO at least 4 hours and have no
contraindication to contrast, ie allergy or renal
insufficiency.

23. Radiation Safety
•Relative values of CT exam exposure
–Background radiation is 3 mSv/year
•Water, food, air, solar
•In Denver (altitude 5280 ft.) 10 mSv/year
–CXR = 0.1 mSv
–CT head = 2 mSv
–CT Chest = 8 mSv
–CT Abdomen and Pelvis = 20 mSv
-The equivalent of 200 CXR

24. Conclusion
•Neuroradiologists are consultants
•CT Terminology
–Attenuation (density) in Hounsfield units
–Digital interpretation is standard of care
•CT has risks
–Contrast
–Radiation exposure

25. MR TERMINOLOGY
•Intensity:
-hyperintense (white)
-hypointense (dark/ black)
-Isointense.

26. T1 AND T2
•Fluid appears dark on T1 (hypointense ) and
bright on T2 ( hyperintense).
•Bones and calcifications appears dark /
black on all sequences.

27. Chronic infarct

28. Normal
CT

29. 1 day 1 year 2 years

30. Normal CT
Older person

31. Normal Enhanced CT

32. Cranio-Facial Trauma

33. CT Brain Angio

34. Temporal Bones

35. Stroke – 2 sec scan

36. Reduced CBF
Reduced CBV Prolonged MTT
Loc CBV CBF MTT
CT perfusion

37. Neck Angiography

38. T1W imaging 3.0T: More detail
1.5T 3.0T
1.5T vs 3.0T
Cortical dysplasia

39. T2W (T2*) FFET1W IR-TSE 3D T1W TFE
(+Gd)
Detection of hemosiderin deposits

40. Detection of venous
anomalies
1.5T 3.0T
16yr Female patient with Right Frontal Intractable Epilepsy

41. ST 1.5T HR 3.0T
High field intracranial MRA
ST 1.5T HR 3.0T

42. MR SPECTROSCOPY

43. PERFUSION MRI

44. DTI - TRACTOGRAPHY

45. Acute infarcts within pons and
cerebellar hemisphere

46. Complete occlusion of basilar and vertebral
arteries

47. Chronic infarct

48. Dural sinus Thrombosis

49. Case 1
•55 yo female with sudden onset of worst
headache of life

50. Case 1

51. Case 1

52. Case 1
•What do I do now?

53. CTA

54. Normal Angiography

55. Diagnostic Angiography

56. Case 1
•Subarachnoid Hemorrhage
–Most common cause is trauma
–Aneurysm
–Vascular malformation
–Tumor
–Meningitis
–Generally a younger age group

57. Case 2
•82 yo male with mental status change after
a fall

58. Case 2

59. Case 2
•Subdural hematoma
•Venous bleeding from bridging veins
•General presentation
–Older age group
–Mental status change after fall
–50% have no trauma history

60. Subdural Hematoma

61. Case 3
•44 yo female with right sided weakness and
inability to speak

62. Case 3

63. Case 3
•Acute ischemic left MCA stroke

64. MCA Stroke
“Dense MCA”

65. Case 4
•50 yo male post head trauma.
•Pt was initially conscious but now 3 hours
post trauma has had a sudden decrease in
his neurological function.

66. Case 4

67. Case 4
•Epidural hematoma
–Typical history is a patient with head trauma
who has a period of lucidity after trauma but
then deteriorates rapidly.
–Hemorrhage is a result of a tear through a
meningeal artery.

68. Case 5
•71 yo male who initially complained of
incoordination of his left hand and
subsequently collapsed

69. Case 5

70. Case 5
•Intraparenchymal hemorrhage
–Hypertensive
–Amyloid angiopathy
–Tumor
–Trauma

71. Case 6
•62 yo female acute onset headache
– Hemiplegic on the right and unable to speak

72. Case 6
•Add htn image here

73. Case 6
•Hypertensive hemorrhage
–Clinically looks like a large MCA stroke
–Generally younger than amyloid angiopathy
patients

74. Chronic Ischemic change =
Encephalomalacia

75. Case 7
•53 y.o. male
•Sudden onset of ataxia loss of
consciousness proceeding rapidly to coma

77. Case 7
•Probable basilar occlusion with cerebellar
and brainstem infarction

78. Case 8
•52 yo male with right sided weakness

79. Case 8

80. Case 8

81. Case 8
•Acute lacunar infarction
–Cannot reliably differentiate this finding on CT
from remote lacune without clinical correlation.

–MRI with diffusion is the GOLD STANDARD
–A word on TIA

82. Chronic Small Vessel Disease

83. Case 9
•59 yo female with multiple falls over last
weekend

84. Case 9

85. Case 9
•Stroke involving caudate head, anterior
limb internal capsule and anterior putamen.

86. Case 10
•42 yo male found in coma

87. Case 10

88. Case 10
•Global ischemia

89. Angiographic Brain Death

90. Case 11
•34 y.o. female
•Severe H/A,nausea
•Taking oral contraceptives

91. Case 11

92. Case 11

93. Case 11
•Transverse sinus thrombosis