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NEURO IMAGING

NEURO IMAGING. Dr. Francis Neuffer Department of Radiology USC - SOM. GOALS AND OBJECTIVES. Review major imaging modalities of neuro imaging . CT, MR, Ultrasound , Angiography Review classic disease states of vascular, traumatic , infectious and neoplastic diseases .

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NEURO IMAGING

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  1. NEURO IMAGING Dr. Francis Neuffer Department of Radiology USC-SOM

  2. GOALS AND OBJECTIVES • Reviewmajorimagingmodalities of neuroimaging. CT, MR, Ultrasound, Angiography • Reviewclassicdiseasestates of vascular, traumatic, infectious and neoplasticdiseases.

  3. DIGITAL SCOUT FILM SHOWING BEGINNING AND END OF CT SCAN. Multiple sectional images are obtained from a preliminary scout image showing the beginning and end of the scan.

  4. iV Contrast enhancement-CT NON-CONTRAST STUDY IV IODINE CONTRAST STUDY

  5. ANATOMY Selected images from CT scans posterior fossa level Basilar Artery Supracellar Cistern Temporal Horn lateral ventricle Pons 4th Ventricle Cerebellum

  6. ANATOMYThalamic level 3rd ventricle Atria Lateral Ventricle Sylvian fissure Thalamus Falx cerebri

  7. ANATOMYInternal capsule level Anterior Horn Lateral ventricle Caudate Nucleus Internal capsule Lentiform nucleus Occipital Lobe

  8. ANATOMYVentricle level Anterior Horn Lateral ventricle Posteror Horn Lateral ventricle

  9. ANATOMYLateral ventricle level Frontal lobe Body lateral ventricle Parietal lobe Occipital lobe Falx cerebri

  10. ANATOMYSupraventricular level Gyrus Centrum Semiovale Sulcus Superior Sagittal Sinus

  11. MAGNETIC RESONANCE Hydrogen protons align in magnetic field Radio frequency(RF) excitation and transmission No ionizing radiation

  12. T1 SCAN MR SIGNAL T2 SCAN SCANS ARE DESIGNED TO SHOW SPECIFIC TISSUE AND SPECIFIC PATHOLOGY

  13. VARIOUS MRI SEQUENCES Thetissuesignalvariesdependingonthetype of scanperformed. T1 T2 (CSF/edema) FLAIR (edema) Diffusion

  14. NORMAL CEREBRAL ARTERIOGRAM NORMAL ULTRASOUND Flow is seen at the common carotid bifurcation on contrast X- ray arteriography and B-mode ultrasound.

  15. CAROTID ARTERY Color Doppler The vessel lumen can be imaged with ultrasound and the velocity of the flow can be measured. A stenotic lesion will show acceleration of flow through the narrowed lumen.

  16. Catheter injection of RT common carotid artery • CCA common carotid A. • ICA internal carotid A. • ECA external carotid A. • MCA middle cerebral A. • ACA anterior cerebral A. ACA MCA ECA ICA CCA

  17. VASCULAR ANATOMY Images of vessels at the Circle of Willis ACA MCA

  18. MR VASCULAR ANATOMY Anterior cerebral Middle cerebral Basilar artery ECA ACA MCA Carotid bulb ICA Vertebral artery CCA ICA MR Angiogram- venous injection Images can be obtained at MR by injecting gadolinium and imaging rapidly as the agent circulates through the arterial circuit.

  19. WHO ARE THE PATIENTS ? • VASCULAR ISCHEMIA • TRAUMA • INFECTIOUS WORKUP • MALIGNANCY WORKUP

  20. CT SCANNINGas initial sorting • Ischemia • Global • Focal Hemorrhage • Hypertensive hemorrhage • Amyloid angiopathy • Hemorrhagic infarction • Subarachnoid hemorhage

  21. FOCAL DEFICIT OF 24 HRS • ACUTE CVA • 85% ISCHEMIC • 15% HEMORRAGHIC • TREATMENT DIFFERENCE • ANTICOAGULATION FOR ISCHEMIC CVA

  22. STENOSIS NORMAL

  23. CT OF ISCHEMIC STROKE 1 DAY POST 2 DAY POST Note increase in edema

  24. LACUNAR INFARCT • Small vessel = lenticulostriatevessel • MCA proximal branch • basal ganglia-thalamic

  25. VASCULAR DISTRIBUTIONS Anterior Cerebral Artery Middle Cerebral Artery Posterior Cerebral Artery The different vascular distributions of cerebral territories are represented on color coded CT diagrams

  26. CT SCANNINGas initial sorting Hemorrhage • Hypertensive hemorrhage • Amyloid angiopathy • Hemorrhagic infarction • Subarachnoid hemorhage

  27. SUBARACHNOID HEMORHAGE Increased density Normal The supra sellar cisterniswhiteduetothebloodmixedwiththe CSF.

  28. SUBARACHNOID HEMORRHAGE Blood in the subarachnoid space Between the Pia & Arachnoid CT – acute blood, increased density Rupture of cerebral aneurysm “Worst Headache of Life” Location: basal cisterns, sylvian fissure, cortical sulci.

  29. CAROTID ANEURYSM Associated with Polycystic Renal disease And Marfans Syndrome Aneurysms are often at vascular branch points and show relative deficit of media there which contributes to vessel wall weakness

  30. INTRACEREBRAL HEMORHAGEHYPERTENSIVE EVENTS Acute Blood is dense on Non contrast CT Pontine Hemorrhage Thalamic Hemorrhage

  31. CEREBRAL AMYLOID ANGIOPATHY (CAA) IS AN IMPORTANT CAUSE OF SPONTANEOUS CORTICAL- SUBCORTICAL INTRACRANIAL HEMORRHAGE (ICH) IN THE NORMOTENSIVE ELDERLY. Chao C P et al. Radiographics 2006;26:1517-1531

  32. Hemorragic infarction—delayed several days Withreperfusiononinfarctareathereishemorrhageintoinfarctzonewith local masseffect and midlineshift.

  33. CT SCANNINGas initial sorting • Ischemia Hemorrhage • Hypertensive hemorrhage • Amyloid angiopathy • Hemorrhagic infarction • Subarachnoid hemorhage

  34. Comparison of infarct zone and ischemic zoneto identify treatment candidates GOAL FOR IMAGING

  35. STROKE INTERVENTION Thrombolytic therapy to salvage ischemic brain at the border of the infarct zone (ischemic penumbra). Who benefits and how to select?

  36. Thrombolytic therapy 3-6 hour window Risk of hemorrhagic conversion STROKE INTERVENTION Typically 3hrs sinceonsetisthelimitforinitiation of venousthrombolytictherapy. With arterial therapythewindow of action can be extended . Therisk of bleedingintotheinfarctzonewithreperfusionis a complicationthat can worsen prognosis.

  37. Lt Rt Note acute occlusion of Rt. MCA circulation and edema in Rt. hemisphere on CT. Comparison of the normal Lt. side is shown.

  38. catheter Catheter is advanced for thrombolysis of the MCA thrombus with improved perfusion on last injection of contrast.

  39. CT vs. MR ?Abnormality on CT Questionable lesion on CT in a Rt. periventricular location.

  40. Compared to CT--MR scans with T1, T2, and diffusion weighted better show the acute evolving ischemic infarction T1 T2 Diffusion

  41. MR vs. CTIN EARLY CVA • MR LIMITATIONS • COMPLEX MR SIGNAL OF HEMORRHAGE • RELATED TO HEMAGLOBIN—Fe EFFECTS • UNSTABLE PATIENT-PATIENT MOTION • MORE A PROBLEM IN MR (LONGER SCAN TIME) • CT READILY VISUALIZES BLOOD PRODUCTS • ACCESS- CT IS AVAILABLE FOR ER PATIENTS

  42. CT SCANNINGas initial sorting • Ischemia • Global • Focal Hemorrhage • Hypertensive hemorrhage • Amyloid angiopathy • Hemorrhagic infarction • Subarachnoid hemorhage

  43. WHO ARE THE PATIENTS? HEAD TRAUMA

  44. SUBDURAL HEMATOMA Venous bleeding from “bridging veins” which connect cerebral cortex to Dural sinuses Concave inner margin Older patient –atrophy enlarged subdural space unstable gait–falls Pediatric patient –shaken baby/child abuse small subdural space can lead to herniation

  45. SUBDURAL HEMATOMA (ACUTE) Over time thebloodbreaksdown and decreases in density.

  46. SUBDURAL HEMATOMA Hit head on RT. With superficial scalp hematoma Subdural hematoma on LT due to tearing of bridging veins with Deceleration with fall.

  47. EPIDURAL HEMATOMA FRACTURE Cause: laceration of meningeal artery/vein adjacent to inner table. Lucid interval post trauma –later cns injury due to mass effect Epidural hematomas are more focal than subdurals since the blood is more confined by the periosteum of the skull.

  48. MIDDLE MENINGEAL ARTERY

  49. SKULL BASE FRACTURE Can lead to cerebral spinal fluid leak and risk of meningitis The purple ecchymosis behind the ear is called Battle sign described as a clinical finding

  50. “RACCOON EYES” Periorbital ecchymosis is another sign of a basal skull fracture. Blood tracks along the periosteum and can collect in soft tissues of the orbital lid. CSF rhinorhea can occur with fractures extending through cribriform plate

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