Laura Tormoehlen, M.D. Neurology and EM-Toxicology Indiana University
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1 Laura Tormoehlen, M.D. Neurology and EM-Toxicology Indiana University
2 Disclosures! No conflicts of interest to disclose
3 Neuroimaging 101! Plain films! Computed tomography " Angiography " Perfusion! Magnetic resonance imaging " Diffusion-weighted Imaging " Spectroscopy " Functional MRI " Diffusion Tensor Imaging! Angiography! Myelography! Ultrasound! Nuclear Medicine " Positron Emission Tomography " Single-photon Emission Computed Tomography " Cerebral Blood Flow
4 Neuroimaging 101! Plain films! Computed tomography " Angiography " Perfusion! Magnetic resonance imaging " Diffusion-weighted Imaging " Spectroscopy " Functional MRI " Diffusion Tensor Imaging! Angiography! Myelography! Ultrasound! Nuclear Medicine " Positron Emission Tomography " Single-photon Emission Computed Tomography " Cerebral Blood Flow
5 Neuroimaging 101! Magnetic resonance imaging " Diffusion-weighted Imaging (DWI) " Spectroscopy (MRS)! Nuclear Medicine " Single-photon Emission Computed Tomography (SPECT) " Cerebral Blood Flow (CBF)
6
7 Introduction! Patterns of abnormal imaging findings: " Diffuse " Focal " Multifocal! Neurotoxic disease " Usually diffuse " Occasionally multifocal " Commonly sub-mri
8 Standard MRI! T1! T2! FLAIR! DWI! ADC! GRE! Contrast needs to be specified
9 MRI sequences! T1 with and without contrast! T2! FLAIR! Diffusion-Weighted Imaging (DWI)! Apparent Diffusion Coefficient (ADC)! Gradient Echo (GRE)! All are done in axial plane, some also done in sagittal and coronal
10 How does a CT scan help?! Screening test " Hemorrhage " Focal lesion " Severe diffuse disease! Trauma/fractures! Calcified lesions! Temporal bone/sinus disease
11 CT versus MR! CT- differential attenuation of x-ray! MR- response of tissue to magnetic field
12 FLAIR imaging! Fluid attenuated inversion recovery! T2-based image! Attenuates the bright signal of CSF on the usual T2 image! White matter = gray! Gray matter = white
13 Comparison (non-contrast) T1 T2 FLAIR
14 Comparison (non-contrast) T2 FLAIR
15 Vasogenic and Cytotoxic Edema Vasogenic Cytotoxic! Reactive process! Bilateral if toxic! Unilateral if surrounding a mass lesion! Predominantly white matter! Improves with steroids! Primary process, tissue injury! Unilateral or bilateral! Affects gray and white matter! Does not respond to corticosteroids
16
17 DWI! Diffusion of water is rapid in normal brain parenchyma and in vasogenic edema (normal signal)! Diffusion is restricted in cytotoxic edema (bright signal)! Apparent diffusion coefficient (ADC) is used to verify diffusion restriction versus artifact
18 DWI/ADC! Non-invasive, physiologic imaging! Highly sensitive to tissue injury " More sensitive than T1/T2/FLAIR " Can show cerebral ischemia within minutes! ADC correlation " Acute vs. chronic infarct " Infarct vs. artifact " Cytotoxic vs. vasogenic edema
19 DWI/ADC
20 Cytotoxic Edema on MRI DWI ADC
21 Acute Ischemic Stroke
22 Acute Ischemic Stroke
23 Acute Ischemic Stroke
24 Acute Ischemic Stroke
25 Acute Ischemic Stroke FLAIR DWI ADC
26 Cerebral Metastatic Disease FLAIR DWI ADC
27 Cerebral Metastases GRE T1 +C
28 Hydrogen Peroxide Ingestion
29 Hydrogen Peroxide Ingestion
30 Hydrogen Peroxide Ingestion
31 Hydrogen Peroxide Ingestion
32 Hydrogen Peroxide Ingestion
33 Hydrogen Peroxide Ingestion
34 Hydrogen Peroxide Ingestion
35 Hydrogen Peroxide Ingestion FLAIR DWI ADC
36 Hydrogen Peroxide Ingestion FLAIR DWI ADC
37 Hydrogen Peroxide Ingestion FLAIR DWI ADC
38 Hydrogen Peroxide Ingestion FLAIR DWI ADC
39 Hydrogen Peroxide Ingestion FLAIR DWI ADC
40 Posterior Reversible Encephalopathy Syndrome
41 Posterior Reversible Encephalopathy Syndrome
42 Posterior Reversible Encephalopathy Syndrome
43 Posterior Reversible Encephalopathy Syndrome
44 Posterior Reversible Encephalopathy Syndrome FLAIR DWI ADC
45 Posterior Reversible Encephalopathy Syndrome FLAIR DWI ADC
46 Posterior Reversible Encephalopathy Syndrome FLAIR DWI ADC
47 Posterior Reversible Encephalopathy Syndrome FLAIR DWI ADC
48 PRES 4 Months Later Initial FLAIR Follow-up FLAIR
49 PRES 4 Months Later FLAIR DWI ADC
50 Delayed Post-Hypoxic Leukoencephalopathy - Heroin FLAIR DWI ADC
51 Delayed Post-Hypoxic Leukoencephalopathy - CO FLAIR DWI ADC
52 Hypoxic-Ischemic Injury
53 Hypoxic-Ischemic Injury
54 Hypoxic-Ischemic Injury
55 Hypoxic-Ischemic Injury
56 Hypoxic-Ischemic Injury
57 Hypoxic-Ischemic Injury
58 Hypoxic-Ischemic Injury
59 Hypoxic-Ischemic Injury
60 Hypoxic-Ischemic Injury
61 Hypoxic-Ischemic Injury FLAIR DWI ADC
62 Hypoxic-Ischemic Injury FLAIR DWI ADC
63 Hypoxic-Ischemic Injury FLAIR DWI ADC
64 Hypoxic-Ischemic Injury FLAIR DWI ADC
65 MRI Summary! FLAIR- white matter edema, demyelination, inflammation, infarction! DWI/ADC- cytotoxic vs. vasogenic edema! T1- metal deposition (copper, manganese)! GRE- hemosiderin! Gadolinium contrast- BBB breakdown
66
67 MRS! Phosphorus! Inorganic phosphorus, ATP! Measures energetic state, ph! Healthy tissue (Krebs cycle) vs. Ischemic tissue (glycolysis)! Proton! Three usual peaks: " Creatine (Cr) " Choline (Cho) " N-acetyl aspartate (NAA)! Lactate
68 MRS! Creatine " Relatively constant! Choline " Elevated with increased cellular turnover (e.g. neoplasm)! NAA " Decreased in neuronal injury (e.g. infarction)! Lactate " Increased in inflammation, infarction
69 MRS Profiles Myoinositol Choline NAA Lactate High grade tumor Necrotic/treated tumor HIE - + Acute Demyelination
70 Classic findings! Demyelination " Decreased NAA, Elevated Cho! Alzheimer Disease " Elevated Myoinositol! Meningiomas " Elevated Alanine! Canavan Disease " Markedly elevated NAA
71 Classic findings! Doublet lactate peak " Stroke " Seizure (recent) " High-grade or necrotic neoplasms! Hypoxic-ischemic encephalopathy " Elevated lactate, Decreased NAA
72 Clinical Uses of MRS! Neoplasm or not! Recurrent neoplasm vs. radiation necrosis! Etiology of leukoencephalopathy! Evaluating for metabolic disease
73 Slides withheld! Images of MRS from literature withheld! See the following references: " Chen-Plotkin AS, et al. Delayed leukoencephalopathy after hypoxic-ischemic injury. Arch Neurol 2008: 65(1): " Gottfried JA, et al. Delayed posthypoxic demyelination: association with arylsulfatase A deficiency and lactic acidosis on proton MR spectroscopy. Neurology 1997: 49: " Chang WC, et al. MRI features of spongiform leukoencephalopathy following heroin inhalation. Neurology 2006; 67: 504.
74 SPECT and Cerebral Blood Flow Study
75 Nuclear Medicine! Infuse radioactive compounds, then detect emissions with gamma cameras! Technetium " Cerebral Blood Flow Study! Indium (CSF) " Hydrocephalus study " Sinonasal CSF leak study! Positron-emitting isotopes " Deoxyglucose PET " Dopamine PET! SPECT
76
77 Cerebral Blood Flow! Technetium 99m-HMPAO! Planar imaging! Imaging delayed after infusion! In brain death, no tracer accumulates = cold study
78 CBF
79 CBF! See the following reference for additional images: " Laurin NR, et al. Cerebral Perfusion Imaging with Technetium-99m HM-PAO in Brain Death and Severe Central Nervous System Injury. J Nucl Med 1989; 30:
80
81 SPECT! Single photon-emission computed tomography! Iodinated radiotracer or technetium agents! Less expensive than PET " Agents are more stable " No cyclotron required! Stroke, Epilepsy, Dementia, Parkinsonism
82 SPECT in Parkinsonism! Radiotracer can be labeled for pre- or post-synaptic sites! Presynaptic " DAT " VMAT " AADC! Postsynaptic " D1 or D2 receptor
83 SPECT in Parkinsonism! See the following reference for images: " Huang CC. Parkinsonism induced by chronic manganese intoxication an experience in Taiwan. Chang Gung Med J 2007; 30:
84 Summary! MR Spectroscopy White matter lesion of unknown etiology! SPECT Differentiation of toxin-induced vs. idiopathic parkinsonism! Cerebral blood flow studies Confirmatory testing for brain death determination in poisoned patient
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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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