Introduction to Neuroimaging Aaron S. Field, MD, PhD Assistant Professor of Radiology Neuroradiology Section University of Wisconsin Madison
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1 Introduction to Neuroimaging Aaron S. Field, MD, PhD Assistant Professor of Radiology Neuroradiology Section University of Wisconsin Madison Updated 7/17/07
2 Neuroimaging Modalities Radiography (X-Ray) Fluoroscopy (guided procedures) Angiography Diagnostic Interventional Myelography Ultrasound (US) Gray-Scale Duplex Color Doppler Computed Tomography (CT) CT Angiography (CTA) Perfusion CT Magnetic Resonance (MR) MR Angiography/Venography (MRA/MRV) Diffusion and Diffusion Tensor MR Perfusion MR MR Spectroscopy (MRS) Functional MR (fmri) Nuclear Medicine Single Photon Emission Computed Tomography (SPECT) Positron Emission Tomography (PET) CT Myelography
3 Radiography (X-Ray)
4 Radiography (X-Ray) Primarily used for spine: Trauma Degenerative Dz Post-op
5 Fluoroscopy (Real-Time X-Ray) Fluoro-guided procedures: Angiography Myelography
6 Fluoroscopy (Real-Time X-Ray)
7 Fluoroscopy (Real-Time X-Ray) Digital Subtraction Angiography
8 Fluoroscopy (Real-Time X-Ray) Digital Subtraction Angiography
9 Digital Subtraction Angiography Indications: Aneurysms, vascular malformations and fistulae Vessel stenosis, thrombosis, dissection, pseudoaneurysm Stenting, embolization, thrombolysis (mechanical and pharmacologic) Advantages: Ability to intervene Time-resolved blood flow dynamics (arterial, capillary, venous phases) High spatial and temporal resolution Disadvantages: Invasive, risk of vascular injury and stroke Iodinated contrast and ionizing radiation
10 Fluoroscopy (Real-Time X-Ray) Myelography Lumbar or cervical puncture Inject contrast intrathecally with fluoroscopic guidance Follow-up with post-myelo CT (CT myelogram)
11 Indications: Myelography Spinal stenosis, nerve root compression CSF leak MRI inadequate or contraindicated Advantages: Defines extent of subarachnoid space, identifies spinal block Disadvantages: Invasive, complications (CSF leak, headache, contrast reaction, etc.) Ionizing radiation and iodinated contrast Limited coverage
12 Ultrasound US transducer carotid
13 Indications: Ultrasound Carotid stenosis Vasospasm - Transcranial Doppler (TCD) Infant brain imaging (open fontanelle = acoustic window) Advantages: Noninvasive, well-tolerated, readily available, low cost Quantitates blood velocity Reveals morphology (stability) of atheromatous plaques Disadvantages: Severe stenosis may appear occluded Limited coverage, difficult through air/bone Operator dependent
14 Ultrasound Gray Scale Gray-scale image of carotid artery
15 Ultrasound Gray Scale Plaque in ICA Gray-scale image of carotid artery
16 Ultrasound - Color Doppler Peak Systolic Velocity (cm/sec) ICA Stenosis (% diameter) >350 >90
17 Computed Tomography (CT)
18 Computed Tomography A CT image is a pixel-by-pixel map of X-ray beam attenuation (essentially density) in Hounsfield Units (HU) HU water = 0 Bright = hyper-attenuating or hyper-dense
19 Computed Tomography Typical HU Values: Brain Air 1000 Fat 100 to 40 Water 0 Other fluids (e.g. CSF) 0 20 White matter Gray matter Blood clot Calcification >150 Bone 1000 Metallic foreign body >1000
20 Computed Tomography Attenuation: High or Low? High: 1. Blood, calcium 2. Less fluid / more tissue Low: 1. Fat, air 2. More fluid / less tissue Air 1000 Fat 100 to 40 Water 0 Other fluids 0 20 White matter Gray matter Blood clot Calcification >150 Bone 1000 Metallic foreign body >1000
21
22 Computed Tomography Soft Tissue Window Bone Window
23 Computed Tomography
24 Computed Tomography Scan axially 2D Recons stack and re-slice in any plane
25 CT Indications Skull and skull base, vertebrae (trauma, bone lesions) Ventricles (hydrocephalus, shunt placement) Intracranial masses, mass effects (headache, N/V, visual symptoms, etc.) Hemorrhage, ischemia (stroke, mental status change) Calcification (lesion characterization)
26 Skull and skull base, vertebrae Fractures
27 Skull and skull base, vertebrae Multiple Myeloma Osteoma
28 Ventricles Hydrocephalus
29 Intracranial masses, mass effects Solid mass Cystic mass
30 Intracranial masses, mass effects L hemisphere swelling Generalized swelling
31 Acute Hemorrhage Intraparenchymal Subarachnoid Subdural Epidural
32 Acute Ischemia Loss of gray-white distinction and swelling in known arterial territory
33 Calcification Hyperparathyroidism
34 CT Angiography 1. Rapid IV contrast bolus 2. Dynamic scanning during arterial phase 3. Advanced 2D and 3D Reconstructions: 2D multi-planar (sagittal, coronal) Volume rendered 3D recons
35 CT Angiography - Head
36 CT Angiography - Head Circle of Willis Vascular Malformations Aneurysms
37 CT Angiography - Neck Carotid bifurcations Vertebral arteries Aortic arch
38 CT Angiography 3D Volume Rendering
39 CT Angiography - Indications Atherosclerosis Thromboembolism Vascular dissection Aneurysms Vascular malformations Penetrating trauma
40 CT Perfusion CBV CBF MTT
41 Hemodynamic Parameters Derived From Concentration-Time Curves Bolus arrival Vein Artery
42 Hemodynamic Parameter Maps Transit Time (sec) Blood Flow (ml/min/g) Blood Volume (ml/g)
43 CT Myelography Spinal CT immediately following conventional myelogram Cross-sectional view of spinal canal along with spinal cord and nerve roots Assess spinal stenosis/nerve root compression (e.g. disc herniation, vertebral fracture, neoplasm)
44 CT Myelography
45 CT Myelography
46 Magnetic Resonance (MR) Hydrogen proton in water or fat MRI
47 Magnetic Resonance Imaging
48 Magnetic Resonance Imaging Transmitter Receiver RF RF = Radio Frequency energy Received signal magnetic field COMPUTER
49 MRI Safety: The Magnet is Always On!
50 Magnetic Resonance Safety MRI Safety Test: Will it: Move? Torque? Get hot? Pass a current? Malfunction? Become a projectile? Get stuck in scanner? Typically safe*: Orthopedic hardware Surgical clips, staples, sutures (older devices must be checked!) Intravascular stents/filters Typically unsafe*: Cardiac pacemakers (and other electrical devices) Some older aneurysm clips Metal fragments in orbit (1 case report) Oxygen tanks, carts, chairs, stools, IV poles, gurneys, etc. Some cosmetics, tattoos, jewelry, hairpins, etc. Pager, watch, wallet, ID badge, pen, keys, pocketknife, etc. * This is an incomplete list and there are many exceptions to every rule When in doubt, check it out!
51 Magnetic Resonance Excited protons relax back to equilibrium T2 T1 Relaxation rates depend on local molecular environment
52 Magnetic Resonance T1-weighted T2-weighted w/ fat suppression
53 Magnetic Resonance T1 T2 Arachnoid Cyst
54 Magnetic Resonance T2 T2 w/ fat suppression
55 Magnetic Resonance T2 T2 w/ fat suppression
56 Magnetic Resonance T2 T2 w/ water suppression (T2-FLAIR)
57 Magnetic Resonance Accentuating blood/calcium blooming T2 T2*
58 Diffusion MR Imaging NORMAL CYTOTOXIC EDEMA (Acute Ischemia) Diffusion MR Signal
59 Magnetic Resonance Imaging Diffusion Highly sensitive to acute ischemia DWI + within a few hours! No other imaging is more sensitive to acute ischemia although perfusion imaging reveals hypoperfused tissue at risk for ischemia Acute left MCA infarction
60 Magnetic Resonance Angiography Axial source images No need for IV contrast! reformatted to maximum intensity projections (MIP) Multiple projections allow 3D-like display
61 Time-Resolved MRA (TRICKS) IV contrast bolus reveals temporal dynamics
62 Magnetic Resonance Angiography with Perfusion MR MRA Perfusion MR
63 Magnetic Resonance Tissue contrast in MR may be based on: Proton density Water/fat/protein content Metabolic compounds (MR Spectroscopy) e.g. Choline, creatine, N-acetylaspartate, lactate Magnetic properties of specific molecules e.g. Hemoglobin Diffusion of water Perfusion (capillary blood flow) Bulk flow (large vessels, CSF)
64 IV Contrast in Neuroimaging 1. CT: Iodine-based Iodine is highly attenuating of X-ray beam (bright on CT) MRI: Gadolinium-based Gadolinium is a paramagnetic metal that hastens T1 relaxation of nearby water protons (bright on T1-weighted images) 2. Tissue that gets brighter with IV contrast is said to enhance (Brightness, in and of itself, is not enhancement!) 3. Enhancement reflects the vascularity of tissue, but The blood-brain barrier keeps IV contrast out of the brain! Enhancement implies BBB is absent or dysfunctional Remember: Some brain anatomy lives outside the BBB
65 1. Vessels 2. Meninges IV Contrast in Neuroimaging Enhancement: pachy = dura lepto = pia-arachnoid 3. Circumventricular organs (structures outside BBB) Pineal gland Pituitary gland Choroid plexus 4. Absent/leaky BBB Some tumors Inflammation Infarction
66 T1 Enhancement T1+C Hemorrhagic melanoma metastasis
67 IV Contrast: Is it Indicated? Typically not Trauma R/O hemorrhage Hydrocephalus Dementia Epilepsy Typically yes Neoplasm Infection Vascular disease Inflammatory disease Always best to provide detailed indication! Radiologist will protocol exam accordingly
68 Advantages: Simpler, cheaper, more accessible Tolerated by claustrophobics No absolute contraindications Fewer pitfalls in interpretation Better than MR for bone detail Disadvantages: Ionizing radiation CT IV contrast complications Need recons for multi-planar Limited range of tissue contrasts MR vs. CT Advantages: MR Much broader palette of tissue contrasts (including functional and molecular) yields greater anatomic detail and more comprehensive analysis of pathology No ionizing radiation Direct multi-planar imaging IV contrast better tolerated (in most pts.) Disadvantages: Higher cost, limited access Difficult for unstable patients Several absolute contraindications (cardiac pacer, some aneurysm clips, etc.) Claustrophobics may need sedation Image interpretation more challenging Lacks bone detail
69 Introduction to Neuroimaging Aaron S. Field, MD, PhD Assistant Professor of Radiology Neuroradiology Section University of Wisconsin Madison
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Index. aneurysm, 92 carotid occlusion, 94 ICA stenosis, 95 intracranial, 92 MCA, 94
A ADC. See Apparent diffusion coefficient (ADC) Aneurysm cerebral artery aneurysm, 93 CT scan, 93 gadolinium, 93 Angiography, 13 Anoxic brain injury, 25 Apparent diffusion coefficient (ADC), 7 Arachnoid
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