applicable neuroradiology for the clinical neurology clerkship lsu medical school new orleans...

Applicable Neuroradiology

For the Clinical Neurology Clerkship

LSU Medical School

New Orleans

Stephen Deputy, MD

Clerkship Director

Applicable NeuroradiologyIntroduction

The field of Radiology first developed following the discovery of X-Rays by Wilhelm Roentgen in 1895. This resulted in widespread clinical use before the damaging effects of ionizing radiation were fully appreciated.

Plain Films of the Skull were the first application of radiological techniques to the field of Neurology and became widespread beginning around 1905

Plain Films of the SkullGood for detecting Ca++

Good for Skull Fx’sGood for Foreign BodiesQuick way to look for pneumatization of

cranial sinuses Plain Spine Films

Good for vertebral fractures and dislocationsUsed in evaluation of scoliosisDoes NOT image cord however

Pneumoencephalogramo Air injected into thecal

sac through LPo Reveals the

ventricular systemo Causes Headaches

(pneumocephaly)o First use in 1918

parenchymal Ca++ and hydrocephalous due to congenital Toxoplasmosis

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

Computed Axial Tomographyo First developed in the 60’so 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

Computed Axial Tomographyo Has advantages of quick acquisition timeo Excellent for picking up acute intracranial bloodo Uses “Houndsfield Units” to determine the density

of structures identifiedo Contrast can be used to better define edema or

any process where there is breakdown of the BBBo Bolus contrast administration provides vascular

anatomy (CT Angiogram)o Contrast administration is contraindicated for use

with renal insufficiency or prior allergy

CT Angiogram showing a Large MCA aneurysm

Contrast-enhanced CTshowing brain abscess and edema

Applicable NeuroradiologyComputed Axial Tomography

o 5 “B” things that are bright (hyperdense) on CTo Bloodo Bone (or Ca++)o Braino Bullet (or foreign body)o “Bontrast” for “Contrast”

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

Neonatal Head U/S with Grade III IVH

Carotid Doppler Ultrasoundshowing ICA stenosis Cranial Doppler with MCA stenosis

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

Ictal SPECT superimposed upon brain MRI

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

PET showing loss of regional stores of Dopamine in patientswith Parkinson’s disease

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

Applicable NeuroradiologyMagnetic Resonance Imaging

T-1 Imaging Water is dark. Fat (Myelin) is brightGadolinium contrast used to show breakdown of BBB

T-2 ImagingWater is bright. Fat is dark.FLAIR (same as T2 except water is “blacked out”)

Diffusion ImagingShows restricted Diffusion of water suggesting cell deathADC Mapping takes into account brightness of background

T2 signal

T1 MRIAxial Plane

T1 MRI with Gadoliniumshowing a brain tumor

T1 Saggital PlaneT1 Coronal Plane

T2 and FLAIR of Multiple Sclerosis

T2 Axial image

Diffusion/Perfusion MismatchL MCA Stroke

T.O.F. MR Angiogram of The Cerebral Vessels

Gadolinium Contrast InjectedMR Angiogram of the Cervical Vessels

MR Venogram of the Cerebral Sinuses and Draining Veins

Applicable NeuroradiologyNeuroanatomy CT Scan

Name The Structures

Ethmoid S.

Clivus

Mastoid Air Cells

Sphenoid S.

Frontal S.

Medulla

Temporal Lobe

Cerebellar Hemisphere 4th V

Sylvian Fissure

Temporal Lobe

3rd Ventricle

Caudate Head Lateral Ventricle

Frontal Lobe

Occipital Lobe

Lateral Ventricle

Falx Cerebri

Frontal Lobe

Occipital Lobe

Parietal Lobe

T1 SaggitalMRI

Frontal Sinus

Sphenoid SinusPituitary

Clivus

Tongue

T1 SaggitalMRI

T1 Saggital MRI

Genu of CC

Body of CC

Splenium of CC

Tegmentum of MidbrainTectal Plate of Midbrain

4th Ventricle

Tonsils

T1 Saggital MRI

T2 Axial MRI

Temporal Lobe

Cerebellar Hemisphere

Vermis

Medulla

T2 Axial MRI

Ethmoid Sinus

Sphenoid Sinus

Temporal Lobe

Int Carotid Artery

Basilar ArteryPons

4 th Ventrical

Cerebellar Hemisphere

T2 Axial MRI

Frontal Sinus

Frontal Lobe

Temporal Lobe

Internal Carotid

Temporal Tip of Lateral Ventricle

Midbrain

Occipital Lobe

T2 Axial MRI

Cerebral Peduncle

Aqueduct of Sylvius

T2 AxialMRI

Frontal Grey M

Frontal White

Head of Caudate

Anterior Horn of Lat Ventricle

Putamen

Thalamus

Splenium of CC

T2 AxialMRI

Anterior Limb Internal CapsuleExternal Capsule

Genu of Internal Capsule

Posterior Limb of Internal Capsule

Caudate Head

Putamen

Globus Pallidus

Thalamus

T2 Axial MRI

T2 CornoalMRI

Cingulate Gyrus

Hippocampus Temporal Lobe

Sylvian Fissure

Superior Saggital Sinus

Basilar Artery

MR Angiogramof CerebralVessels

Internal Carotid Artery

Middle Cerebral Artery

Ant Cerebral Artery

Vertebral Artery

Basilar Artery

MR Angiogram of Cerebral Vessels

Vertebral Artery

Superior Cerebellar Artery

A1 segment of ACA

M1- segment of MCA

MR Venogram of Cerebral Vessels

Superior Saggital S.

Torcula

Transverse S.

Internal Jugular Vein

Straight S

What is the Abnormality?

Large MCA Stroke

Hemorrhagic Conversion

T1 Axial MRI T2 Axial MRI

Decreased Signal Increased

signal

DWI restriction ADC Map

Old Gliosis

Sub Dural HematomaMass Effect

Epidural hematomaMass Effect

Subarachnoid Hemorrhage

Glioma

Metastatic Brain Tumors

Hydrocephalus

Transependymal Edema

Syringomyelia

Bonus Round

T2 Axial MRI 4 y.o. with

Gelastic Seizures

T2 Axial MRI

Hypothalamic Hamartoma

4 y.o. with Gelastic Seizures

T2 Axial MRI 10 y.o. with Developmental Delay and Epilepsy

T2 Axial MRI

Schizencephaly/Polymicrogyria

10 y.o. with Developmental Delay and Epilepsy

The End

applicable neuroradiology for the clinical neurology clerkship lsu medical school new orleans...

ct o blood o bone

contrast slide

ca o brain o bullet

axial tomography o

edema slide

s o digital geometry

mca stenosis slide

cerebral vasospasm slide

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