RADIOLOGY FOR PRACTITIONERS IMAGING OF COMMON NEUROLOGICAL DISORDERS

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1 RADIOLOGY FOR PRACTITIONERS IMAGING OF COMMON NEUROLOGICAL DISORDERS Roul HOURANI, Mukil H. HOURANI* Hourni R, Hourni MH. Imging of common neurologicl disorders. J Med Lin 2009 ; 57 (1) : Neurordiology is clinicl suspecilty deling with the dignosis of diseses of the rin nd spinl cord, using rdiologicl equipment: computed tomogrphy, mgnetic resonnce imging, ngiogrphy nd digitl r d i o g r p h y. In this rticle, we will ddress the issue how physicins should mke decisions out using imging, wht study is the most pproprite nd for us, the foremost question should ny imging e performed? ecuse mny times imging is wsteful nd in those cses, greter degree of consulttion etween referring clinicins nd rdiologists is crucil. Adiscussion of the rdiologicl evlution of some clinicl prolems like hedches with nd without fever, rin trum, ischemic stroke, seizure, dizziness will e presented. H E A D A C H E S Hedches constitute one of the most frequent resons of neurology consulttion. Their cuses re extremely vried. The first step consists in the nlysis of the chrcteristics of the pin nd the ssocited signs in order to distinguish primry nd secondry hedches. Primry hedches, including migrines nd tension-type hedches re the most frequent types nd do not require imging evlution. An isolted hedche or clssic migrine unccompnied y neurologicl signs does not require imging evlution. Secondry hedches re relted to n orgnic cuse nd require specific investigtions [1]. The lrming signs of hedche include ptients older thn 50 yers old, cute severe hedche, cute hedche with rpid progression, unusul hedche, hedche in immunocompromised individuls, hypertensive ptients s well s in pregnnt women, nd hedches ssocited with fever, neurologicl signs nd chnge in mentl sttus. For sudden severe (thunderclp) hedche ssocited with neck stiffness, nuse nd vomiting, surchnoid hemorrhge (SAH) is the first dignosis to e considered nd rin imging with CT or MRI plys n importnt role in the dignosis workup. CT scn without contrst will demonstrte the lood in the surchnoid spces nd sl cisterns (Figure 1). If MRI is ville, fluidttenuted inversion recovery (FLAIR) nd susceptiilityweighted imging MR sequences or grdient echo sequences could e lso useful. A C T n g i o g r p h y, MR ngiogrphy or ctheter ngiogrphy is recommended FI G U R E 1. Axil non-enhnced CTof the rin shows () hyperdensity in the sl cisterns nd sylvin fissures representing surchnoid hemorrhge. () There is round hyperdensity ( r r o w) representing the left nterior cererl rtery neurysm. *From the Deprtment of Dignostic Rdiology, Americn University of Beirut Medicl Center, Beirut, Lenon. Correspondence: Roul Hourni, MD. Americn University of Beirut Medicl Center. Deprtment of Dignostic Rdiology. POBox Rid El Solh Beirut. Lenon. Tel: Fx: e-mil: rh 6 u. e d u. l

2 FIGURE 2. 3D reconstruction mximum intensity projection [MIP] of circle of Willis CT ngiogrphy demonstrtes left middle cererl rtery [MCA] neurysm (rrow). to evlute the presence of neurysm [2-3]. The new multidetector CT scnners hve 69 to 97% sensitivity in the dignosis of cererl neurysm [4-7] (Figure 2). MR ngiogrphy (MRA) ws used less frequently for dignosing neurysm, nevertheless, it is useful for neurysm follow-up fter endovsculr tretment (coiling) nd it hs sensitivity rnging from 52% to 97% nd specificity rnging from 86% to 100% (Figure 3) [8-9]. An cute hedche ssocited with unilterl neck pin nd Bernrd-Horner syndrome is suggestive of rteril dissection. In this cse evlution with duplex ultrsound nd neck MRI nd MRA re useful for the evlution of hemtom in the rteril wll (Figure 4). Unusul hedches my e secondry to cererl venous thromosis, sinusitis, otitis or dentl cuses. Cererl venous thromosis is suspected when we hve sinonsl or dentl infection, in stte of hypercogulility; i.e. history of cncer nd in ptients under orl FIGURE 3. 3D reconstruction mximum intensity projection [MIP] of mgnetic resonnce ngiogrphy [MCA] of the circle of Willis revels iloed neurysm t the right MCA ifurction (rrow). FIGURE 4. Axil diffusion imge of the rin demonstrtes right MCA cute infrct.. Axil T 2 WI t the level of the skull se revels crescent sign in the right internl crotid rtery [ICA] (rrow) comptile with right ICAdissection s demonstrted in the 3D MIP MRA of neck (c). The right ICAis nrrowed with string sign ( rrow). c 6 Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

3 contrceptive tretment. MRI is the est imging technique to evlute the presence of thromus in the durl sinuses on T 1, T 2 nd FLAIR sequences s well s the presence of venous hemorrhgic infrct (Figure 5). A n MR venogrphy (MRV), with or without contrst; or CT venogrphy with contrst lso help in the visuliztion of the sinus thromosis (Figure 5) [10]. Acute hedche with rpid progression my e secondry to intrcrnil tumor; in this cse the hedche is usully ssocited with norml neurologicl signs, nuse nd vomiting. MRI is the gold-stndrd technique to evlute rin tumors, the ntomic sequences, like T 1 c d FIGURE 5. Sgittl T 1 WI of the rin shows norml high signl in the superior spect of the superior sgittl sinus representing cute thromus.. 3D MIP reconstruction of rin MR venogrphy [MRV] demonstrted sence of flow relted enhncement in the superior spect of the superior sgittl sinus. c-d. Axil T 2 WI nd T 2* of the rin show multiple corticl nd sucorticl high signl intensity lesions with hypointense foci on T 2* imge representing venous hemorrhgic infrcts. Note the sence of flow voids in the superior sgittl sinus (rrow). R. HOURANI et l. Imging of Common Neurologicl Disorders Lenese Medicl Journl 2009 Volume 57 (1) 7

4 nd T 2 re useful for locliztion nd definition of tumorl extent. The new MR imging technique (e.g. perfusion nd spectroscopy) re recommended to evlute the grde of cererl gliom (Figures 6, 7 nd 8) nd distinguishing tumors from non neoplstic rin lesion such s tumefctive multiple sclerosis nd inflmmtory lesions [11 ]. Hedche ssocited with fever rises the dignosis of meningitis/encephlitis. A rin CT is recommended to rule out rin lesion, nd if it is norml, lumr puncture is dvised to rech dignosis. Brin MRI will demonstrte norml T 2 high signl intensity in the cererl prenchym nd corticl diffusion normlities loclized in the mesil temporl loes, postero-inferior frontl loes nd the insul in cse of herpes encephlitis (Figure 9); however, MRI my e norml t the initil stge of the disese nd tretment with cyclovir should e initited s soon s possile. Mny reports highlight the usefulness of diffusion weighted imging (DWI) for erly detection nd dignosis of herpes encephlitis [12]. Hedche during pregnncy nd postprtum period is usully enign in 90% of cses; however we should keep in mind hedche secondry to venous thromosis, surchnoid hemorrhge nd eclmpsi. In this cse, dignostic imging is importnt to detect the presence of SAH, thromus, or T 2 high signl intensity in the posterior region of the rin indictive of posterior reversile encephlopthy syndrome (PRES) (Figure 10) [13]. FI G U R E 6 Axil enhnced T 1 WI of the rin () shows non-enhncing lesion in the left thlmus. The corresponding perfusion cererl lood volume [ C B V ] mp is shown (). Region of interest in the tumor (L1) nd in the contrlterl norml white mtter (L4) demonstrte reltive CBVof 0.5 comptile with low grde gliom WHO II confirmed y iops y. FI G U R E 7 Axil enhnced T 1 WI of the rin () shows e n h n c i n g tumor in the right sl gngli with surrounding edem, the ptient is sttus post right frontl crniotomy. The corresponding perfusion cererl lood volume (CBV) mp is shown (). Region of interest in the tumor (L3) nd in the contrlterl norml white mtter (L4) demonstrte reltive CBVof 6.4 comptile with high grde gliom WHO III-IVconfirmed y iopsy. FI G U R E 8 Axil T 1 -weighted SE loclizer imge, FLAIR imge, xil contrst-enhnced T 1 -weighted SE MR imge with proton MR spectr of the lesion (voxel 2) nd the corresponding control spectrum (voxel 1) in 38-yer-old womn with primry CNS lymphom. There is T 2 hyperintensity involving the left temporoprietl loe with miniml mss effect; the lesion exhiits ptchy heterogeneous enhncement on the post-gdolinium imges. Compred with the contrlterl side, the metolite imges nd spectr of the lesion show elevted Cho nd Cr, nd decresed NAAsignls, with n NAA/Cho rtio of Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

5 c d FIGURE 9 -. Axil T 2 WI nd coronl fluid ttenution inversion recovery [FLAIR] imges of the rin show T 2 high signl intensity in the right temporl loe nd oth insul comptile with herpes encephlitis. c-d. Axil T 2* nd T 1 WI of the rin show hyposignl on T 2* in the mesil right temporl loe nd gyrl T 1 high signl comptile with hemorrhge. c FIGURE 10. Axil non-enhnced CT scn of the rin shows corticl sucorticl hypodensities in oth prietl loes. - d. Axil FLAIR () shows high signl in the prietl nd frontl loes ilterlly. A x i l d i ffusion (c) showing high signl in the right prietl loe with no evidence of restricted diffusion in the ADC mp (d). d e e. Axil FLAIR fter one month show complete resolution of the norml high signls confirming the reversile nture of thelesions in the setting of PRES.

6 c FIGURE 11. Axil T 2 STIR shows ring lesion in the right frontl loe with surrounding edem.. Coronl enhnced T 1 WI s show multiple ring enhncing lesion in the rin comptile with spergillous scesses. c. ADC mp shows restricted diffusion within the scess. Hedche in hypertensive nd immunocompromised ptients should lwys e evluted y imging to eliminte n underlying lesion like hemtom in the former condition nd tumor or scess in the ltter (Figure 11) [14]. Primry hedches or other chronic hedches cn e triggered y sinonsl pthologies. Hedche of rhinogenic origin is usully progressive ssocited with occsionl fcil pin or swelling nd fever. These ptients my experience considerle relief of hedche following nti-inflmmtory tretment, ntiiotics or surgery. When it is suspected specil dignostic nd therpeutic ttention needs to e given to ptients [15-16]. Evlution of the prnsl sinuses is est chieved y mens of CT scn without contrst with coronl reconstruction to evlute the ostiometl complexes. An enhnced CT or MRI is recommended if tumor is suspected, e.g. in cse of nsl leed. In immunocompromised ptients with fungl sinusitis n MRI of the sinuses nd rin fter gdolinium dministrtion is crucil to rule out intrcrnil, oritl extension nd secondry cvernous sinus thromosis. FIGURE 12 Axil non-enhnced CT scn imges of the rin show left nterior temporl contusion with intr-prenchyml hemtom () nd in nother ptient left temporl sudurl hemtom isodense contining hyperdense foci comptile with cute lood (). 10 Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

7 FIGURE 13. Axil non-enhnced CT of the rin shows hyperdense right MCA (rrow).. Axil non-enhnced CT of the rin shows effcement of the right insulr rion nd hypodensity in the right MCAterritory comptile with cute right MCAinfrct. HEAD TRAUMA Hed trum is the most common cuse of deth in young dults. Erly neuroimging hs n importnt role in evluting the extent nd severity of injury. A rin CT without contrst is the first imging stndrd to evlute rin trum. It is required in ptients with one or more of the following chrcteristics (ccordingly to the Europen Brin Injury Consortium): severe nd moderte hed injury; ful consciousness with skull frcture; confusion persisting fter initil resuscittion; unstle systemic stte precluding trnsfer to neurosurgicl unit; uncertin dignosis [17]. Urgent CT exmintion is required in the presence of rpid neurologicl deteriortion or signs of developing rin hernition. Beside tht, there re some clinicl risk fctors significntly correlted to n norml rin CT fter hed i n j u r y, they include: vomiting, skull frcture nd ge greter thn 60 yers. The presence of severl risk fctors in ptient incresed the proility of posttrumtic lesion on CT scn [18]. Persistent hedche, mnesi, loss of consciousness, focl neurologicl deficit nd cogulopthy or ntecedent of tretment with nticogulnts were not significntly ssocited with normlity on rin CT. In the cse of trum, CTor MRI my demonstrte sudurl, epidurl, or intrprenchyml hemtoms (Figure 12), surchnoid hemorrhge, skull frcture; MRI is etter to evlute diffuse xonl injury on DWI nd smll mount of leed on the susceptiility-weighted MR sequence T 2*. In recent study of 40 children with trumtic rin injury, Sigmund et l. demonstrte tht T 2, FLAIR, nd susceptiility-weighted imging provide more ccurte ssessment of injury severity nd ptient s outcome thn does CTin peditric rin trum. However, CT remins n essentil prt of the cute rin trum workup to evlute the need for neurosurgicl intervention [19]. ISCHEMIC STROKE Stroke is the third leding cuse of deth fter myocrdil infrction nd cncer nd the leding cuse of permnent disility in Western countries. New nd dvnced dignostic imging techniques for cute stroke trige hve the potentil to not only improve the qulity of cre, ut lso reduce helth cre costs. Noncontrst CT scn is the current imging stndrd for cute stroke, ecuse of its wide vilility nd ner 100% sensitivity for the detection of cute intrcrnil hemorrhge, the most importnt differentil dignosis to ischemic stroke. Previously, it ws widely ssumed tht unenhnced CT is norml within the first six hours of ischemi onset; however, there re erly ischemic signs tht re ecoming more recognized nd re resulting from tissue wter increse within the ischemic territory; they include: dense vessel, loss of definition of the gry-white orders giving oscurtion of the lentiform nucleus nd the corticl or insulr rion sign (Figure 13). Dense vessel typiclly consists of red thromus. Within 12 to 24 hours well delineted hypodense region is pprent corresponding to the ischemic territory of the ffected vessel. Ptients who hve extensive erly ischemic sign (hypodensity lrger thn one third of the middle cererl rtery territory) hve smll chnce of good clinicl outcome nd should e excluded from thromolysis due to the high risk of hemorrhge. CT is lso importnt for the ssessment of hemorrhgic trnsformtion fter thromolysis [20]. Multimodl CT imging, including noncontrst CT, C T n g i o g r p h y, nd CT perfusion, is now incresingly reserved for cute stroke cses with contrindictions to MR imging. CT ngiogrphy is eing used to ssess vessel sttus nd CTperfusion will ssess different hemo- R. HOURANI et l. Imging of Common Neurologicl Disorders Lenese Medicl Journl 2009 Volume 57 (1) 11

8 c FI G U R E 14. Axil diffusion WI () nd corresponding ADC mp () demonstrte right prieto-occipitl cute infrct with low A D C comptile with restricted diffusion. Axil cererl lood volume mp (c) shows decrese CBV in the infrcted re. FIGURE 15 Axil diffusion WI () nd the corresponding men trnsit time (MTT) perfusion mp () demonstrte the core of the infrction s high signl on diffusion in the right coron rdit; lrgest hypoperfused re is demonstrted on perfusion corresponding to the infrct plus the penumr in the right prieto-occipitl re (rrow). The difference etween the diffusion nd perfusion imges is clled mismtch equl to the penumr re, trget for therpy. FIGURE 16 Coronl FLAIR () nd spoiled grdient echo (SPGR) () imges of the rin revel high signl intensity in the right hippocmpus (rrow) which is smller in size when compred to the left side comptile with right mesil temporl sclerosis. 12 Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

9 dynmic prmeters like: cererl lood flow, cererl lood volume, men trnsit time (MTT) nd time-to-pek (TTP). Those prmeters will e extensively explined nd detiled lter in the MR perfusion-weighted imging s e c t i o n. MR imging hs the potentil to ecome the most widely nd uniformly used tool to guide stroke therpy. The MR imging protocols used for evlution of cute stroke cses hve evolved with the introduction of novel sequences, mximizing the mount of imging dt ville for therpeutic decision-mking within the shortest period of time. The stroke protocols tke 10 minutes for cquisition. It includes: D i ffusion-weighted imging (DWI) provides informtion regrding the dignosis of ischemic stroke, including loction nd extent. Restricted diffusion hs een principlly ttriuted to cytotoxic edem in the core of the infrction, representing the irreversile ischemic injury (Figure 14). Grdient echo sequence is used for the detection of cute nd chronic intrcrnil hemorrhge, including cererl microleeds which indicte poor outcome fter thromolysis nd, therefore, should e used to improve ptient selection. Fluid ttenuted inversion recovery (FLAIR) sequence revels erly prenchyml chnges ssocited with ischemi nd prior cererl lesions. Perfusion-weighted imging (PWI) using dynmic contrst enhncement with gdolinium. PWI llows the qulittive ssessment of vrious hemodynmic prmeters like cererl lood flow, cererl lood volume, men trnsit time (MTT), nd time-to-pek (TTP). Ares of reltive hypoperfusion cn e relily demonstrted y the cererl lood flow (CBF) nd cererl lood volume mps; the quntifiction of the CBF will then chrcterize the tissue s norml, reversily ischemic, or irreversily dmged (Figure 14c). The reversily ischemic tissue is clled the ischemic penumr defined s the rin regions tht re t risk for infrction ut remins slvgele nd, hence, the trget of cute stroke therpy. The TTP mps revel perfusion delys cused y elongted collterl routes nd re used for prompt evlution of diffusion-perfusion mismtch which is the volume difference of DWI nd PWI tht gives n pproximte mesure of the tissue t risk for infrction, trget of thromolytic therpy (Figure 15) [21]. MR ngiogrphy of the intrcrnil nd extrcrnil circultions re cquired to identify lrge vessel occlusions, trget of the endovsculr therpies (intr-rteril or intrvenous thromolysis). SEIZURE Epilepsy is common, chronic, neurologicl disorder chrcterized y recurrent seizures. The epilepsies re clssified into generlized nd focl [22]. Prtil or focl seizures originte from loclized re of the rin, wheres generlized seizures originte from oth cererl hemispheres. CT hs role in the initil evlution of seizures when ssocited with focl neurologicl chnges, fever, trum, or in n emergency setting; however, MR imging is the modlity of choice in the evlution of epilepsy ptients tht should e performed in the nonemergent setting. It is n excellent tool for detecting epileptogenic structurl normlities; however, it is of little enefit in ptients with idiopthic generlized epilepsy. In prtil epilepsy MRI my demonstrte: hippocmpl sclerosis (mesil temporl sclerosis) (Figure 16), mlformtions of corticl development like heterotopi nd corticl dysplsi (Figure 17), neoplsms, vsculr c FIGURE 17 Axil T 2 WI () nd coronl FLAIR () imges show right frontl corticl thickening nd high signl intensity with no evidence of norml enhncement on enhnced T 1 WI (c). The lesion corresponds to corticl dysplsi s demonstrted y pthology. R. HOURANI et l. Imging of Common Neurologicl Disorders Lenese Medicl Journl 2009 Volume 57 (1) 13

10 FIGURE 18 Axil enhnced T 1 WI () shows multiple lesions hving hypointense rim comptile with hemosiderin deposit nd centrl hyperintense foci representing lood, overll findings comptile with multiple cvernoms. Axil T 2 * WI () of nother ptient shows multiple hypointense lesions in the rin, representing cvernoms. normlities like rteriovenous mlformtions (AVMs) nd cvernous mlformtions (Figure 18), gliosis nd miscellneous normlities tht include: 1. Posttrumtic epilepsy secondry to hemtom, contusions nd gliosis. 2. Infections like tuerculosis nd neurocysticercosis. 3. Rsmussen s encephlitis nd 4. Sturge-Weer syndrome, congenitl neurocutneous syndrome chrcterized y the ssocition of ipsilterl fcil ngiom in the distriution of the trigeminl nerve with leptomeningel ngiomtosis [23-24]. for some cses of sound-induced vertigo. Dehiscence of the superior semicirculr cnl results in Tullio s phenomenon which is vertigo or other norml vestiulr senstions ccompnied y eye nd/or hed movements in response to sound. The dignosis is estlished y CT of the temporl ones with coronl reconstruction (Figure 20) [29-32]. DIZZINESS Dizziness is common symptom tht hs een reported to hve prevlence of 28-34% in dults over the ge of 60 [25]. Despite the evlution with mny clinicl nd imging studies, lrge percentge of ptients often hve no explntion for their prolem. There re severl cuses for dizziness including etiologies such s vsculr, inflmmtory, trumtic, metolic, neoplstic, congenitl, nd drug relted cuses. T h e metolic, inflmmtory nd drug relted vertigo groups usully do not require imging investigtion. When vsculr etiology is suspected (verterosilr insuff i- ciency nd other crdiovsculr cuses), evlution with rin MRI, MR or CT ngiogrphy is recommended. Demyelintion like multiple sclerosis within the rinstem or long nerves my lso cuse these similr symptoms nd MRI scnning of the rin is indicted [26]. One of the most common indictions for MRI is vertigo ssocited with sensorineurl hering loss. In generl, the usul dignosis which is to e excluded is vestiulr schwnnom (Figure 19), or other neoplstic etiologies of the cereello-pontine ngle, inner er nd internl uditory cnls [27-28]. R e c e n t l y, the superior semicirculr cnl dehiscence syndrome hs een explined s possile etiology FIGURE 19 Axil FLAIR of the posterior foss demonstrtes lrge lesion of the right cereello-pontine ngle, extending into the right internl uditory cnl, showing centrl necrosis nd representing vestiulr schwnnom. There is significnt mss effect on the right cereellum nd the 4 th ventricle with surrounding vsogenic edem. 14 Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

11 FIGURE 20 Coronl reconstruction of temporl one CT scn revels the dehiscence of the superior semi-circulr cnl (rrow). CONCLUSION In this pper we reviewed some neurologicl prolems with their neurordiologicl investigtions; however, lrge numer of diseses nd their imging findings were not discussed like congenitl rin nd spine lesions, CNS metolic diseses, spinl cord lesions nd tumors, spine, pituitry diseses, s well s orit nd neck lesions tht need to e detiled in er-nose nd throt (ENT) imging pper. REFERENCES 1. Goldstein JN, Cmrgo CA, Pelletier AJ, Edlow JA. Hedche in United Sttes emergency deprtments : demogrphics, workup nd frequency of pthologicl dignoses. Cephllgi Jun ; 26 (6) : Strin JD. ACR Appropriteness Criteri on hedchechild. J Am Coll Rdiol 2007 Jn ; 4 (1) : Strin JD, Strife JL, Kushner DC, Bcock DS, Cohen HL, Gelfnd MJ, Hernndez RJ, McAlister WH, Prker BR, Royl SA, Slovis TL, Smith WL, Rothner AD. Hedche. Americn College of Rdiology. ACR A p p r o p r i t e n e s s Criteri. Rdiology 2000 Jun ; 215 (Suppl) : Brcrd S, White PM, Wrdlw JM, Tesdle EM. Cn noninvsive imging ccurtely depict intrcrnil neurysms? A systemtic review. Rdiology 2000 ; 217 : Chppell ET, Cstro Moure F, Good MC et l. Comprison of computed tomogrphic ngiogrphy with digitl sutrction ngiogrphy in the dignosis of cererl neurysms : metnlysis. Neurosurgery 2003 ; 52 (3) : Young N, Dorsch NWC, Kingston RJ et l. Intrcrnil neurysms : evlution in 200 ptients with spirl CT ngiogrphy. Eur Rdiol 2001; 11 : Brcrd S, Anxionnt R, Picrd L. Current dignostic modlities for intrcrnil neurysms. Neuroimging Clin N Am 2006 Aug ; 16 (3) : White PM, Tesdle EM, Wrdlw JM et l. Intrcrnil neurysms : CT ngiogrphy nd MR ngiogrphy for detection - prospective linded comprison in lrge ptient cohort. Rdiology 2001 ; 219 : Chung TA, Joo JY, Lee SK et l. Evlution of cererl neurysms with high-resolution MR ngiogrphy using section interpoltion technique : correltion with digitl sutrction ngiogrphy. Am J Neurordiol 1999 ; 20 : Khndelwl N, Agrwl A, Kochhr R et l. Comprison of CT venogrphy with MR venogrphy in cererl sinovenous thromosis. Am J Roentgenol 2006 Dec ; 187 (6) : Hourni R, Horsk A, Alyrm S, Brnt LJ, Melhem E, Cohen KJ, Burger PC, Weingrt JD, Crson B, Whrm MD, Brker PB. Proton mgnetic resonnce spectroscopic imging to differentite etween nonneoplstic lesions nd rin tumors in children. J Mgn Reson Imging 2006 Fe ; 23 (2) : Kuker W, Ngele T, Schmidt F, Heckl S, Herrlinger U. Diffusion-weighted MRI in herpes simplex encephlitis : report of three cses. Neurordiology 2004 Fe ; 46 (2) : Osorn A, Blser S, Slzmn, K : Dignostic Imging : Brin, first ed, Sunders, 2004 : Guvrit JY, Leclerc X, Moulin T et l. Hedches in the emergency context. J Neurordiol 2004 Sep ; 31 (4) : Cshmn EC, Burns P, Smyth D. Sinus hedche : clinicl dilemm. Ir Med J 2007 Fe ; 100 (2) : Cooper W, Sper JR. Teching cse: Sinus hedche. Hedche 2007 Mr ; 47 (3) : Ms AI, Derden M, Tesdle GM, Brkmn R, Cohdon F, Innotti F, Krimi A, Lpierre F, Murry G, Ohmn J, Persson L, Servdei F, Stocchetti N, Untererg A. EBICguidelines for mngement of severe hed injury in dults. Europen Brin Injury Consortium. Act Neurochir (Wi e n ) 1997 ; 139 (4) : Soori M, Ahmdi J, Frjzdegn Z. Indictions for rin CT scn in ptients with minor hed injury. Clin Neurol Neurosurg 2007 Jun ; 109 (5) : Sigmund GA, Tong KA, Nickerson JP, Wll CJ, Oyoyo U, Ashwl S. Multimodlity comprison of neuroimging in peditric trumtic rin injury. Peditr Neurol 2007 Apr ; 36 (4) : Kucinski T. Unenhnced CTnd cute stroke physiology. Neuroimging Clin N Am 2005 My ; 15 (2) : Lieeskind DS, Kidwell CS; UCLA Thromolysis Investigtors. Advnced MR imging of cute stroke : the University of Cliforni t Los Angeles endovsculr therpy experience. Neuroimging Clin N Am 2005 My ; 15 (2) : Commission on Clssifiction nd Terminology of the Interntionl Legue ginst Epilepsy. Proposl for revised clssifiction of epilepsies nd epileptic syndromes. Epilepsi 1989 ; 30 : Vttiplly VR, Bronen RA. MR imging of epilepsy : strtegies for successful interprettion. Mgn Reson Imging Clin N Am 2006 My ; 14 (2) : Vttiplly VR, Bronen RA. MR imging of epilepsy: strtegies for successful interprettion. Neuroimging Clin N Am Aug ; 14 (3) : R. HOURANI et l. Imging of Common Neurologicl Disorders Lenese Medicl Journl 2009 Volume 57 (1) 15

12 25. Slone PD, Coeytux RR, Beck RS et l. Dizziness : stte of the science. Ann Intern Med 2001; 134 : Hourni R, Crey J, Yousem DM. Dehiscence of the jugulr ul nd vestiulr queduct : findings on 200 consecutive temporl one computed tomogrphy scns. J Comput Assist Tomogr 2005 Sep-Oct ; 29 (5) : Eton DA, Rolnd PS. Dizziness in the older dult, Prt 2. Tretments for cuses of the four most common symptoms. Geritrics 2003 ; 58 : Eton DA, Rolnd PS. Dizziness in the older dult, Prt 1. Evlution nd generl tretment strtegies. Geritrics 2003 ; 58 : Minor LB. Superior cnl dehiscence syndrome. Am J Otol 2000 ; 21 : Minor LB, Solomon D, Zinreich JS et l. Sound- nd/or pressure-induced vertigo due to one dehiscence of the superior semicirculr cnl. Arch Otolryngol Hed Neck Surg 1998 ; 124 : Kcker SK, Hinchcliffe R. Unusul Tullio phenomen. J Lryngol Otol 1970 ; 84 : Fox EJ, Blkny TJ, Arenerg IK. The Tullio phenomenon nd perilymph fistul. Otolryngol Hed Neck Surg 1988 ; 98 : Lenese Medicl Journl 2009 Volume 57 (1) R. HOURANI et l. Imging of Common Neurologicl Disorders

Fundamentals of Spine MRI and Essential Protocols

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