mgh neuroradiology review course - amazon s3...mgh neuroradiology review course 5/29/16 1 mhl / mgh...
TRANSCRIPT
1
MGH Neuroradiology Review Course
5/29/16 1
MHL / MGH
How to Acquire/interpret Head CT, H&N CTA, and Brain MRI
Michael H Lev, MD FAHA FACR Director, Emergency Radiology & ED Neuroradiology
Massachusetts General Hospital Professor of Radiology
Harvard Medical School MHL / MGH
Disclosures GE Healthcare
Consultant Research support (MGH) Common stock (< $10K)
D-Pharm Consultant
MedyMatch Consultant
MLNM Pharm Consultant
MHL / MGH
Father Guido Sarducci�s Philosophy
SNL 1980�s �You forget 95% of everything you learn in school� �My course only teaches the 5% you remember”
�Neurology for the House Officer� Weiner and Levitt
Last chapter: Neuroanatomy
MHL / MGH
History Essential for both detection and interpretation … really just need the following 4 items …
Age? Stroke etiology
Gender? MS
Acuity of Onset? Stroke MS, ICH vs stroke Tumor
Specifc sx, immune status? Spinal level Toxo vs lymphoma
MHL / MGH MHL / MGH
2
MGH Neuroradiology Review Course
5/29/16 2
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
3
MGH Neuroradiology Review Course
5/29/16 3
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
4
MGH Neuroradiology Review Course
5/29/16 4
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
5
MGH Neuroradiology Review Course
5/29/16 5
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
6
MGH Neuroradiology Review Course
5/29/16 6
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
Other NCCT Considerations Artifact
Beam-hardening �Spray�; metallic – solution dual energy? Tilt / reconstruction plane �Fogging�
CORONALS – since 2008/9 at MGH … Henson et al, AJNR 2010 MUST USE IN ALL TRAUMA
– Tentorial, falx SDH; subtle SAH – Blow out fracture – Anterior temporal and frontal contusions
7
MGH Neuroradiology Review Course
5/29/16 7
MHL / MGH
Value of Reformats: Avoid False Negatives
(A rare case for which sagittal > coronals …)
MHL / MGH
Subtle SDH Level 30 Window 100
Level 80 Window 200
MHL / MGH
HU Helps: �Swirl Sign� is HIGHLY SPECIFIC For Expansion of Acute Hemorrhage
MHL / MGH
… if it is true swirl sign … But Almost All Acute Bleeds at MGH get CTA
MHL / MGH
CTA �Spot Sign� Predicts Hematoma Growth: High NPV!
Goldstein, …, Lev, Rosand. Neurology 2007 Mar 20;68(12):889-94 Delgado, Yoo, Romero, et al. Stroke 2010
MHL / MGH MR
Sag CT
Wood is Hypodense Chopstick Injury
8
MGH Neuroradiology Review Course
5/29/16 8
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
9
MGH Neuroradiology Review Course
5/29/16 9
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
10
MGH Neuroradiology Review Course
5/29/16 10
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
11
MGH Neuroradiology Review Course
5/29/16 11
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
12
MGH Neuroradiology Review Course
5/29/16 12
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
13
MGH Neuroradiology Review Course
5/29/16 13
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
14
MGH Neuroradiology Review Course
5/29/16 14
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
“Low Tech” Pearl: Early ‘Ionic’ Edema?
Sensitivity improved from 57% to 71% Advice to non-experts: use ASPECTS!
30 mm Slabs at 5 mm Intervals
Overlapping Thick Slab MIPS*
MHL / MGH
Checking Stroke CTA’s at the Scanner: Overlapping Thick Slab MIPS (Not for SAH!*)
• By tech at scanner in 3 planes ~ 1min • Triage decisions made before patient off table!
30 mm thick at 5 mm intervals
Courtesy of Stuart Pomerantz, MD
15
MGH Neuroradiology Review Course
5/29/16 15
MHL / MGH
From Brian Greene: The Hidden Reality
(Superimposition of hi freq / low freq transformed image data)
MHL / MGH
MHL / MGH MHL / MGH
MHL / MGH MHL / MGH
Scan Review Layout
Leon Harmon produced the famous Lincoln illusion in 1973
16
MGH Neuroradiology Review Course
5/29/16 16
MHL / MGH MHL / MGH
�Golfe Juan�: Paul Signac, 1884 (WAM)
MHL / MGH
A Sunday Afternoon on the Island of La Grande Jatte, George Suerat, 1884
Courtesy Stu Pomerantz, MD MHL / MGH
FBP: 250 mA FBP: 200 mA ASIR:200 mA
ASIR: improved gray-white differentiation due to TRUE DECREASED NOISE* c/w same or higher dose FBP
The �graininess� to which radiologists have become accustomed
is not a true feature of brain anatomy!
�Waxy�?: Does the Brain have Grain?
MHL / MGH