University Hospitals Case Medical Center

Department of Radiology

1 – chiasma2 – brainstem3 – frontal sinus4 – orbit

5 – temporal lobe (middle cranial fossa)6 – mastoid air cells7 – cerebellar hemispheres

7 – cerebellar hemispheres8 – interhemispheric fissure9 – frontal horn (lateral ventricle)10 – falx cerebri11 – frontal lobe

12 – third ventricle13 – quadrigeminal plate19 - thalamus20 – caudate nucleus21 – basal ganglia

8 – interhemispheric fissure9 – lateral ventricle11 – frontal lobe14 – septum pellucidum15 - sulci

16 – central sulcus17 – chorioid plexus18 – occipital lobe22 – parietal lobe

Extra-axial hemorrhage Epidural hematoma Subdural hematoma Subarachnoid hemorrhage

Intra-axial hemorrhage Intraparenchymal hemorrhage Intraventricular hemorrhage

Hemorrhage in the potential space between the inner table of the skull and dura matter

Causes Blunt trauma - injury to middle meningeal

artery/vein 95% associated skull fracture

Signs High-density, Extra-axial Biconvex lens-shaped mass Does NOT cross sutures CAN cross tentorium

Hemorrhage in the potential space between the dura mater and the arachnoid space

Causes Damage to bridging veins that cross from the

cortex to the venous sinuses of the brain Deceleration injuries (MVA) Falls (older patients)

Signs High-iso-low density

Depends on acuity Concave, crescent shaped CAN cross sutures Does NOT cross midline

Hemorrhage into the subarachnoid space Between the pia and arachnoid membranes

Causes Arteriovenous malformation Aneurysm rupture Trauma

Signs Hyperdense Within the sulci

and basal cisterns Intraventricular

blood

Hemorrhage within the brain parenchyma Causes

Hypertensive/Hemorrhagic Stroke Trauma Blood Vessel abnormalities

Arteriovenous Malformation Aneurysm Rupture

Intracranial Neoplasm Cerebral Amyloid Angiopathy Coagulopathy

Signs Well demarcated area of high attenuation Surrounded by hypoattenuation

Edema Associated mass effect

Compression of ventricles Effacement of sulci Midline shift Subtentorial herniation

Can have intraventricular blood

Trauma - Closed head injury Coup (Point of impact)

Shearing of small intracerebral vessels Countercoup (Opposite the point of impact)

Acceleration/deceleration injuries Brain propels in the opposite direction

Hypertensive Hemorrhagic Stroke 15% of strokes Location

Basal ganglia, thalamus, pons, cerebellum

Hemorrhage in the ventricular system Cause - Breakthrough bleeding

Brain contusion or subarachnoid hemorrhage Signs

Most common location Occipital horns (lateral ventricles)

Can cause obstructing hydrocephalus

Intra-axial mass Metastasis

Primary intra-axial mass - ADULTS Glioblastoma multiforme

Primary intra-axial mass – CHILDREN Medulloblastoma (PNET)

Extra-axial mass Meningioma

Most common intra-axial mass Primary Malignancies

Lung, Breast, Melanoma Signs

Well-defined Near Gray-White Junction Multiple or Solitary Surrounding edema Enhances with contrast

SOLITARY MULTIPLE

Gliomas are the most common primary intra-axial malignancy in adults GBM – most common glioma

Poor prognosis Male (age 65-75) > Female Signs

Supra-tentorial Necrotic and Infiltrative Cross midline – “butterfly” glioma Enhances with contrast Significant vasogenic edema, mass effect

Most common primary intra-axial tumor in children

Primitive neuroectodermal tumors (PNET) Male > Female Peak age 3-5 years Signs

Infratentorial – Cerebellum Effacement of the 4th ventricle, basal cisterns

Hydrocelphalus Hyperdense Necrosis +/- Calcifications Enhances with contrast

Most common extra-axial mass Benign - Slow growing – good prognosis Middle-aged Female > Male Association - NF-2 Signs

Hyperdense +/- calcifications +/- edema Enhance with contrast Dural Tail

Questions?

Please read the supplemental article on cervical spine trauma

Neuro quiz will be administered on Thursday at 11:30AM before conference