Keep Imaging Simple: An Introduction To Neuroimaging
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1 Keep Imaging Simple: An Introduction To Neuroimaging Meghan Elkins, OD, FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.
2 Disclosure Statement: Nothing to disclose
3 COURSE OBJECTIVES Brief radiation introduction Brief review of how X-rays, CTs, and MRIs work Recognize anatomic structures for normal patients Examples of pathologic and incidental findings
4 RADIATION
5 RADIATION Ionizing Radiation: DNA damage d/t high energy wavelengths Natural occurring sources: sun, radon Millisieverts (msv) NOT measured by Geiger counter Quantity of radiation dose Milligray (mgy) Approximate dose of radiation absorbed
6 RADIATION RISKS msv Comparisons Chest X-Ray Hour Flight 0.1 Lumbar Spine X-Ray 1.5 Head CT 2 Chest CT 5 Angiogram 16 Potential for increased cancer risk if multiple CT scans
7 X-RAYS!
8 INDICATIONS qhistory of metal in/around eyes qused prior to MRI
9 EXAMPLES!
10 EXAMPLES!
11 COMPUTED TOMOGRAPHY CT
12 INDICATIONS Trauma Exophthalmos Acute CVA Cellulitis Sinus Visualization And many more!
13 CT STRATEGY Utilizes x-rays and computer algorithms to visualize bone and organ structures Best for blood and bone Black and white images: Tissue density White à High density à bone Black à Low density à air
14 CT REPORTS Technique Slice size Location Method DLP: Dose Length Product Required by law Total energy into pt Findings Impression
15 CONTRAST Iodine based Required for CTA Contraindications: Allergy Asthma Kidney Issues Pregnancy Children Blocks or attenuates x-rays Anywhere contrast goes, enhancement follows Hyperdense Brighter
16 CONTRAST Not needed for imaging of high density structures Hemorrhagic stroke Bony structures Metallic Foreign bodies Wood = contrast helps BUN/Creatinine GFR > 60 = okay < 30 = not okay
17 NO CONTRAST CONTRAST
18 MAGNETIC RESONANCE IMAGING MRI
19 BACKGROUND Uses magnets! CT is good for bones and blood MRI is good for anatomy and soft tissue Depends on hydrogen nuclei which release energy absorbed from short electromagnetic pulsations
20 BACKGROUND Two main imaging sequences T1 T2 Weighting: measurement of excited proton relaxation time after magnet turned off Specific tissues have different relaxation times viewed best in either T1or T2
21 CONTRAINDICATIONS Metal unless manufactured approved Tattoos BUSTED in 2004 Claustrophobia (relative) 350+ lbs (relative)
22 CONTRAINDICATIONS Metal unless manufactured approved Tattoos BUSTED in 2004 Claustrophobia (relative) 350+ lbs (relative)
23
24 T1-WEIGHTED Normal anatomy highlighted Recovery time < 1000 msec Vitreous will help you determine which type of scan you are looking at (CSF will, too) DARK Vitreous = HYPOintense = T1 Utilize T1 images with contrast to compare enhancements
25 T2-WEIGHTED Pathologies highlighted: water and edema are Recovery time > 1000 msec Bright CSF/Vitreous = HYPERintense = T2 Blood = black
26 T1 VS T2 CHART Tissue T1 T2 CSF Dark Bright Muscle Gray Dark Gray Fat Bright Light Gray Air Very Dark Very Dark Inflammation Dark Bright Adapted from Accessed: 01/29/2018.
27 MRI WITH CONTRAST Gandolinium based Blood-brain barrier T1 images Enhanced images = Tumors Inflammation BUN/Creatinine à Calculate GFR Omniscan > 60 Prohance Contrast Contraindicated < 30 Less adverse events than iodine
28 FAT SUPPRESSION Suppresses bright signal from fat: Better visualizes orbital structures Tumors Inflammation Vascular Malformations Short T1 Inversion Recovery: best for optic neuritis Optic nerve enhancement post-contrast Must have fat suppression
29 FLUID ATTENUATION INVERSION RECOVERY Recovery time > 1000 msec Suppresses bright CSF on T2 Vitreous is also dark Remember: T2 should have a bright vitreous VERY useful for demyelination (periventricular plaques) Useful for pathology near sinuses
30 DIFFUSION WEIGHTED IMAGING Acute infarcts! = BAD Significant artifacts Poorer resolution Typically T2-weighted May have T2 shine-through ADC Map Post-processing used in conjunction with DWI Dark = Bad
31 OTHER OPTIONS MRA Contrast not needed Blood moves through vessels producing dark signal but bright on MRA d/t series of images processed Circle of Willis! MRV Example: venous sinus thrombosis No contrast
32 OTHER OPTIONS Orbital CT No need for fat suppression Fat is inherently dark on CT Orbital MRI Must use fat suppression technique Supposedly: cannot do in open MRI
33 T2 T1 FLAIR T2 FLAIR DWI ADC EXAMPLES Many more strategies!
34 ANATOMIC REVIEW
35 ANATOMIC REVIEW Axial Sagittal
36 AXIAL SCANS 3 1. Medulla 2. Cerebellum 3. Maxillary Sinus 4. Masseter Muscle 5. Semicircular Canals
37 AXIAL SCANS 3 1. Pons 2. Fourth Ventricle 3. Ethmoid Sinus 4. Basilar Artery 5. Internal Carotid Artery 6. Temporal Lobe 7. Sphenoid Sinus
38 AXIAL SCANS 1. Pons Almost Midbrain! 2. Superior Cerebral Peduncle 3. Tegmentum 4. Temporal Lobe 5. Cavernous Sinus
39 AXIAL SCANS 6 1. Midbrain 2. Cerebral Aqueduct 3. Cerebellum 4. Straight Sinus 5. Occipital Lobe 6. Optic Nerve
40 AXIAL SCANS 1. Higher Midbrain 2. Inferior Colliculus 3. Pituitary Stalk 4. Optic Tract 5. Optic Chiasm 6. Mammillary Bodies 7. Occipital Lobe
41 AXIAL SCANS 1. Superior Colliculus 2. Superior Sagittal Sinus 3. Occipital Lobe 4. Temporal Lobe 5. Third Ventricle
42 AXIAL SCANS Corpus Callosum 2. Septum Pellucidum 3. Lateral Ventricles 4. Superior Sagittal Sinus 5. Frontal Lobe 6. Parietal Lobe
43 CORONAL SCANS
44 SAGITTAL SCANS 1
45 FUN FINDINGS CT MRI
46 CALCIFICATIONS Pineal Gland Choroidal Plexus
47 ISCHEMIC STROKE T2 FLAIR T2
48 ORBITAL INFLAMMATION
49 BRAIN ABSCESS
50 ORBITAL FRACTURE (CT)
51 WHAT DOES AN INTRAOCULAR FOREIGN BODY LOOK LIKE?
52 IDIOPATHIC INTRACRANIAL HYPERTENSION
53 T1 post MENINGIOMA 60-something wm No complaints Incidental finding: pseudopapilledema vs papilledema MRIs ordered STAT Patient came back to eye clinic to await results T1 Pre T2 Pre
54 GENERALIZED ATROPHY
55 RETINAL CALCIFICATIONS
56 CHOROIDAL MELANOMA T1 FLAIR Fat Sat T1 FLAIR
57 AV MALFORMATION
58 SOURCES 1. Radiation risk from medical imaging. Published: October Accessed: 4 October The millisievert and milligray as measures of radiation dose and exposure. Accessed: 4 October Mettler FA, et al. "Effective Doses in Radiology and Diagnostic Nuclear Medicine: A Catalog," Radiology (July 2008), Vol. 248, pp Tiny FB picture: 5. Cat picture: 6. Magnetic Resonance Imaging (MRI) of the Brain and Spine: Basics. Accessed: 01/29/ Korchi, AM, et al. Imaging of the cavernous sinus lesions. Diagnostic and Interventional Imaging. (95)9: September This lecture could not have been possible without the assistance of Dr. Amina Tariq, Staff Radiologist, Huntington VAMC.
59 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18
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