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Imaging of the CNS

Imaging of the CNS. Contents. Diagnostic tools Anatomical localization: Brain Diseases: - Infection - Tumor - Trauma - Stroke - Cord compression. Tools. Plain film CT MR Angiography. Plain radiography. 5 densities. Air Fat Soft tissue (water,muscles,etc)

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Imaging of the CNS

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  1. Imaging of the CNS

  2. Contents • Diagnostic tools • Anatomical localization: Brain • Diseases: - Infection - Tumor - Trauma - Stroke - Cord compression

  3. Tools • Plain film • CT • MR • Angiography

  4. Plain radiography

  5. 5 densities • Air • Fat • Soft tissue (water,muscles,etc) • Bone, calcification • Metallic

  6. Adventage - Convenience - Safe - Fast - Availability Indication Fracture skull Increase ICP Intrasellar mass Osteolytic/ osteoblastic lesion Calcifying pathology Advantage & I/C

  7. View and positioning

  8. PA • Petrous pyramid อยู่ภายในกระบอกตา • Frontal bone and parietal bone • Frontal sinus • Nasal cavity • Mandible • Roof of orbits

  9. Lateral skull • Cranial vault • Suture : coronal and lambdoid • Occipital bone • Sellar turcica • Floor of cranial fossa • Clivus • Nasopharyngeal soft tissue • Sphenoid air sinus • lateral of calvarium • lateral of mandible • Cervical spine 1st-2nd

  10. Lateral Outer table Suture Diploic space Sellar turcica Inner table External occipital protuberance Sphenoid air sinus

  11. Caldwell view • Orbital wall • Frontal and ethmoid sinuses • Mandible

  12. Caldwell view Ethmoid sinus Maxillary sinus Orbital wall

  13. Towne’s view • Occipital bone • Lamdoid suture • Foramen magnum • Petrous ridge และ mastoid sinuses • Zygomotic arch • Mandible ส่วน head, neck และ rami

  14. Waters’ view • Facial bone • Orbital roof • Maxillary, frontal and ethmoid sinus

  15. Waters’ view Frontal sinus Orbital wall Maxillary sinus

  16. Paranasal sinuses Water’ s view Caldwellview

  17. Paranasalsinusitis Air-fluid level at both maxillary and both frontal sinuses

  18. Linear fracture skull right parietal bone

  19. Nasal bone Fx nasal bone Outer table destruction : histiocytosis X

  20. Normal sella turcica Anterior clinoid Posteriorclinoid Dorsum sellae Floor of sella

  21. ICP “loss of dorsum sella sign”

  22. Pituitary tumor “Double floor sign”

  23. Large intrasella mass 1 3 2 “ballooning sella”

  24. CT : Pituitary tumour CECT

  25. CT scan

  26. CT /Spiral CT/ MDCT

  27. CT scan Advantage - Axial imaging - Reconstruction, reformatted to coronal, sagittal planes - Providing contrast- noncontrast study - Differentiation tissues by densities(HU) - Additional software: CTA, CTV, 3D, CTP etc.

  28. Indication • Trauma case • 1st line imaging of Stroke • Infection • Tumor • Intracranial calcification • C/I: pregnancy, contrast enhancement injection: limited in patient with azotemia

  29. Attenuation number of CT (HU)Hounsfield Units • CSF = 0-20 HU. • Gray matter = 40 HU. • White matter = 23-46 H • Clot blood & hematoma = 70-100 HU. • Calcification and bone = +100-200 HU. • Fat = -100-200 HU. • Air = >- 600 HU. • Density ของ lesion ใดๆจะดูเทียบกับ gray matter

  30. Normal CT brain Gray matter White matter Basal ganglia cerebellum Thalamus

  31. Normal CT brain : Ventricular system Temporal horn Frontal horn Lateral ventricle 4th ventricle Occipital horn

  32. Physiologic calcification • Pineal gland • Age > 10 year • Size < 10 mm. • Basal ganglia • Middle aged • Young aged : hypoxia or abnormal serum Calcium • Choroid plexus • Dura • Falx cerebri • Calcification of diaphragmatic sellae

  33. Enhancement by contrast media • Abnormal blood brain barrier (BBB) • Identify vascular and dural structures • Differential pathology by pattern of enhancement

  34. DSA

  35. ANGIOGRAM – MCA BIFURCATION ANEURYSM

  36. MCA aneurysm

  37. 25-YEAR-OLD NORMOTENSIVE MAN WITH UNEXPLAINED ICH LT ICA ANGIOGRAM – AVM

  38. Indication • Gold standard for vascular imaging ( ex. Aneurysm, AVM) • Arterial / venous • Risk=1% • C/I : azotemia, pregnancy

  39. MRI machine

  40. MRI • Magnet Field : 0.5-3Tesla • Pulse sequences : Spin Echo ( SE) • Parameters : T1 : T2 : TR : TE

  41. Advantage MRI • Multiplanar imaging ( axial/coronal/sagittal/any planar) • No radiation • No bony artifact • Safer contrast agent (Gadolinium) • Best for analysis:posterior fossa and leptomeningeal lesions

  42. MRI- three planars Axial CoronalSagittal

  43. Contraindications • Implantable Cardiac defibrillator • Pace Maker • wt. > 136 Kg • Severe Claustrophobia • Pregnancy (+/- ) • Cochlear Implant • Aneurysm Clips • Ferromagnetic eye prosthesis / F.B.

  44. BRAIN : GM : WM Muscles Nerve :dorsal root :ventral CSF Fat Pituitary: anterior posterior T1WT2W intermediate high high low intermediate intermediate intermediate intermediate intermediate low high high low Intermediate intermediate high high SIGNAL INTENSITY(SI) Tissue

  45. T1WI

  46. T2WI

  47. MRI of brain tumor T2W T1W-GD T1W

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