Applicable Neuroradiology
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1 For the Clinical Neurology Clerkship LSU Medical School New Orleans Amy W Voigt, MD Clerkship Director
2 Introduction The field of Radiology first developed following the discovery of X-Rays by Wilhelm Roentgen in This resulted in widespread clinical use before the damaging effects of ionizing radiation were fully appreciated.
3 Plain Films of the Skull were the first application of radiological techniques to the field of Neurology and became widespread beginning around 1905
4 Plain Films of the Skull Good for detecting Ca ++ Good for Skull Fx s Good for Foreign Bodies Quick way to look for pneumatization of cranial sinuses Plain Spine Films Good for vertebral fractures and dislocations Used in evaluation of scoliosis Does NOT image cord however
5 Pneumoencephalogram o Air injected into thecal sac through LP o Reveals the ventricular system o Causes Headaches (pneumocephaly) o First use in 1918 parenchymal Ca ++ and hydrocephalous due to congenital Toxoplasmosis
6 Cerebral Angiography First used in 1927 via direct percutaneous internal carotid artery puncture Useful for defining cerebral vasculature Was used to infer tumors or other mass lesions based on the displacement of vascular structures
7 Computed Axial Tomography o First developed in the 60 s o Digital geometry is used to create a 3 dimensional image of the internal aspects from a large series of 2 dimensional X-ray images taken around a single axis of rotation
8 Computed Axial Tomography o Has advantages of quick acquisition time o Excellent for picking up acute intracranial blood o Uses Houndsfield Units to determine the density of structures identified o Contrast can be used to better define edema or any process where there is breakdown of the BBB o Bolus contrast administration provides vascular anatomy (CT Angiogram) o Contrast administration is contraindicated for use with renal insufficiency or prior allergy
9 CT Angiogram showing a Large MCA aneurysm Contrast-enhanced CT showing brain abscess and edema
10 Computed Axial Tomography o 5 B things that are bright (hyperdense) on CT o Blood o Bone (or Ca ++ ) o Brain o Bullet (or foreign body) o Bontrast for Contrast
11 Cranial Ultrasound Cranial U/S developed in the 70 s Used in infancy as a non-invasive way to view ventricles and look for intraventricular hemorrhage using the anterior fontanelle as a portal Used in adults for carotid stenosis/dissection or for cerebral vasospasm
12 Neonatal Head U/S with Grade III IVH Carotid Doppler Ultrasound showing ICA stenosis Cranial Doppler with MCA stenosis
13 SPECT Single Photon Emission Computed Tomography Developed in 60 s (along with CT) gamma ray-emitting long-acting isotope (Technetium-99m) shows regional CBF Can help localize seizure onset (Ictal-SPECT) Can be superimposed on CT or MRI More available than PET
14 Ictal SPECT superimposed upon brain MRI
15 PET Positron Emission Tomography Developed in the 70 s Detects gamma rays released by a radionuclide tracer linked to a marker FDG (Fludeoxyglucose) most commonly used Other markers include specific neurotransmitters or their receptors Requires cyclotron to make short half-life tracers so not as available as PET
16 PET showing loss of regional stores of Dopamine in patients with Parkinson s disease
17 Magnetic Resonance Imaging Developed in the 80 s Powerful magnetic fields cause water molecules to align along their dipoles Radiofrequency waves produce an electromagnetic field which transiently knocks the molecules out of alignment When water molecules re-align within the magnetic field they release energy (photons) which are detected by scanners and following a lot of computer mumbo-jumbo an image is produced
18 Magnetic Resonance Imaging T-1 Imaging Water is dark. Fat (Myelin) is bright Gadolinium contrast used to show breakdown of BBB T-2 Imaging Water is bright. Fat is dark. FLAIR (same as T2 except water is blacked out ) Diffusion Imaging Shows restricted Diffusion of water suggesting cell death ADC Mapping takes into account brightness of background T2 signal
19 Blood on MRI is paradoxical and evolves Note the intensity changes as the blood cells break down and lose oxygen For ACUTE Blood they are similar to FAT T1 = White T2 = Black
20 Axial T1 Acute Hemorrhage Axial T2 Acute Hemorrhage
21 T1 MRI Axial Plane T1 MRI with Gadolinium showing a brain tumor
22 T1 Sagital Plane T1 Coronal Plane
23 T2 and FLAIR of Multiple Sclerosis T2 Axial image
24 Diffusion/Perfusion Mismatch L MCA Stroke
25 T.O.F. MR Angiogram of The Cerebral Vessels Gadolinium Contrast Injected MR Angiogram of the Cervical Vessels
26 MR Venogram of the Cerebral Sinuses and Draining Veins
27 Neuroanatomy: CSF Review majority of CSF is produced from in choroid plexus in the two lateral ventricles. passes through the interventricular foramina to the third ventricle then the cerebral aqueduct to the fourth ventricle. the fluid passes from 4 th ventricle to enter the subarachnoid space
28 Neuroanatomy Name The Structures
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31 C l i v u s
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36 Temporal Lobe Cerebellar Hemisphere
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39 Lateral Ventricle Sylvian Fissure 3 rd Ventricle
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42 Falx Cerebri Frontal Lobe Lateral Ventricle Occipital Lobe
43 T1 Sagital MRI Applicable Neuroradiology
44 T1 Saggital MRI Applicable Neuroradiology
45 T1 Saggital MRI Frontal Sinus Clivus Tongue
46 T1 Sagital MRI
47 T1 Saggital MRI
48 T1 Saggital MRI Splenium of CC Tegmentum of Midbrain Tectal Plate of Midbrain 4 th Ventricle
49 T2 Axial MRI Applicable Neuroradiology
50 T2 Axial MRI Applicable Neuroradiology
51 T2 Axial MRI Temporal Lobe Cerebellar Hemisphere V e r m i s
52 T2 Axial MRI
53 T2 Axial MRI
54 T2 Axial MRI Temporal Lobe Pons
55 T2 Axial MRI
56 T2 Axial MRI
57 Frontal Sinus T2 Axial MRI Temporal Lobe Occipital Lobe
58 T2 Axial MRI
59 T2 Axial MRI Aqueduct of Sylvius
60 T2 Axial MRI
61 T2 Axial MRI
62 T2 Axial MRI Splenium of CC
63 T2 Axial MRI Applicable Neuroradiology
64 T2 Axial MRI Applicable Neuroradiology
65 Caudate Head Globus Pallidus T2 Axial MRI
66 T2 Coronal MRI Applicable Neuroradiology
67 T2 Cornoal MRI Applicable Neuroradiology
68 T2 Cornoal MRI Superior Saggital Sinus Sylvian Fissure Hippocampus Temporal Lobe
69 MR Angiogram of Cerebral Vessels
70 MR Angiogram of Cerebral Vessels
71 MR Angiogram of Cerebral Vessels Basilar Artery Internal Carotid Artery
72 MR Angiogram of Cerebral Vessels
73 MR Angiogram of Cerebral Vessels Applicable Neuroradiology
74 MR Angiogram of Cerebral Vessels ICA
75 MR Venogram of Cerebral Vessels
76 MR Venogram of Cerebral Vessels
77 MR Venogram of Cerebral Vessels Internal Jugular Vein
78 What is the Abnormality?
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80 Large MCA Stroke
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86 T1 Axial MRI FLAIR Axial MRI
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88 DWI restriction ADC Map
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92 Mass Effect
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94 Subarachnoid Hemorrhage
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98 Edema
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100 Metastatic Brain Tumors
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102 Hydrocephalus
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104 Syringomyelia
105 Bonus Round
106 T2 Axial MRI 4 y.o. with Gelastic Seizures
107 T2 Axial MRI 4 y.o. with Gelastic Seizures
108 T2 Axial MRI 10 y.o. with Developmental Delay and Epilepsy
109 T2 Axial MRI 10 y.o. with Developmental Delay and Epilepsy
110 The End
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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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