Download - Neuroimaging Resident
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Plain film of skull
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Normal sella turcica
Posterior clinoidAnterior clinoid
Dorsum sellae
Floor of sella
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ICP
loss of dorsum sella sign
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Pituitary tumor
Double floor sign
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Large intrasella mass
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3
1
ballooning of
sella
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Anatomy
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MedullaInferior
CerebellarPedancle
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Basillar a.
Pons
Forth ventricle
Temporallobe
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Pons
PituitaryFossa
Forth ventricle
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Midbrain
Gyrus rectus of frontal lobe
MCA
Medial
temporal
Amygdala
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PosteriorLimb of int. capsule
Occipital lobe
Caudate
Ant limb of
Int. capsule
Putamen
Sylvian fissure
Thalamus
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Lateral ventricle
Splenium
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Frontal lobe
Parietal lobe
Central sulcus
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CT brain
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Computed tomography (CT)scan
Cross-sectional representation ofanatomy created by a computer-generated analysis of the attenuation
of x-ray beams passed through asection of the body
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CT scan: indication
Primary study of choice inEvaluation of acute trauma to the brainand spine
Subarachnoid hemorrhage,
CT is complementary to MR in theevaluation of the skull base, orbit, andosseous structures of the spine.
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CT scan
Intravenous contrast is oftenadministered prior to or during a CTstudy to
identify vascular structures detect defects in the blood-brain
barrier (BBB), which are associated withdisorders such as tumors, infarcts, and
infections.
Carried risk for allergic reaction,nephrotoxicity
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CT scan
Advantage
Availability
Shorter scan time
Detection of hemorrhage Disadvantage
Contrast media
Artifacts in posterior fossa or area surrounded by
bone Radiation exposure is between 3 and 5 cGy per
study
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CT brain check list
CT brain with/without contrast
Soft tissue, bony structure, sinus, orbit,mastoid
Meninges, CSF space surrounding brain
Brain parenchyma Abnormal hyper/hypodensity lesion+location
Abnormal calcification +location
Grey-white differentiation +location
Edema Location
Pressure effects on ventricle
Midline shift
herniation
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CT brain check list
Ventricles Any pressure effect on ventricles from edema
Abnormal dilatation of ventricle
Contrast enhancement Location
Pattern: nodular, gyral, ring, homogeneous,inhomogeneous
Others Abnormal vascular structure
Hyperdense MCA
Empty delta sign
Pituitary, pineal
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CT brain check list
Diagnosis Diagnosis
Location and SIDE!!!
Stage: acute, subacute, chronic (ifindicated)
Other important findings: eg. Withherniation
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MRI
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Magnetic resonance imaging (MRI
Complex interaction between hydrogenprotons in biologic tissues, a staticmagnetic field (the magnet), and
energy in the form of radiofrequency(Rf) waves of a specific frequencyintroduced by coils placed next to the
body part of interest
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MRI
Advantage Better resolution esp. temporal lobe,
posterior fossa, spinal cord MRA/MRV
Special techniques: DWI Disadvantage Availability
Longer scan time Interpretation of hemorrhage
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MRI of the brain
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MRI of the brain
MRS
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Use ofMRI in emergency
situation
Very early case of ischemic stroke
Cerebral venous sinus thrombosis
Acute spinal cord compression
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Contraindication forMRIscan Cardiac pacemaker or permanent pacemaker
leads
Internal defibrillatory device Cochlear prostheses
Bone growth stimulators
Spinal cord stimulators
Electronic infusion devices
Intracranial aneurysm clips (some but not all)
Ocular implants (some) or ocular metallic foreignbody
McGee stapedectomy piston prosthesis
Omniphase penile implant Swan-Ganz catheter
Magnetic stoma plugs
Magnetic dental implants
Magnetic sphincters
Ferromagnetic IVC filters, coils, stentssafe 6
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MRI
T1W T2W
CSF Grey matterWhite matter
CSF
Grey matterWhite matterLesion, edem
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FLAIR (fluid attenuated inversion recovery)
CSF Grey matterWhite matter
Lesion, edema
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Case 1
57 year old woman presented to theER with sudden onset lefthemiparesis 2 hours before arriving
at the ER
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Answer
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CT brain check list
CT brain with/without contrast
Soft tissue, bony structure, sinus, orbit,mastoid
Meninges, CSF space surrounding brain
Brain parenchyma Abnormal hyper/hypodensity lesion+location
Abnormal calcification +location
Grey-white differentiation +location
Edema Location
Pressure effects on ventricle
Midline shift
herniation
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CT brain check list
Ventricles Any pressure effect on ventricles from edema
Abnormal dilatation of ventricle
Contrast enhancement Location
Pattern: nodular, gyral, ring, homogeneous,inhomogeneous
Others Abnormal vascular structure
Hyperdense MCA
Empty delta sign
Pituitary, pineal
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Description
CT brain without contrast Soft tissue, bony structure, sinus, orbit,
mastoid- normal
Hypodensity lesion in the rightfrontoparietal region
Loss of gray white differentiation/ loss ofsulci in the right frontoparietal region
Edema in the right frontoparietal region withpressure effect on right lateral ventricle
No midline shift
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CT brain check list
Diagnosis Diagnosis
Location and SIDE!!!
Stage: acute, subacute, chronic (ifindicated)
Other important findings: eg. Withherniation
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Diagnosis
Acute right middle cerebral arteryinfarction
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Left hyperdensed
MCA sign
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Anterior choroidal a.
Posterior cerebral a.
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Case 2
40 years old man
Was sent to ER due to confusion
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Answer
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Lensshapeextra-axiallesion
Softtissueswelling
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DescriptionCT brain without contrast
Soft tissue swelling at the rightfrontal region
Normal orbit and bony structuresLens-shape, extra-axial hyperdensitylesion overlying the right frontal lobe
Some pressure effect to the adjacentbrain and ventricles
No midline shift
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DiagnosisAcute epidural (or Extradural)haematoma at right frontal lobe
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Case 3
50 years old man
Was sent to ER due to confusion
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Answer
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Extra-axiallesion
withpressure
effect
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DescriptionCT brain without contrast
Normal orbit, sinus and bonystructure
Isodensity, extra-axial, concave
lesion overlying left fronto-parietalarea
With midline shift to the left
With pressure effect on the adjacentbrain and obliteration of the leftlateral ventricle
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DiagnosisSubacute subdural haematoma atleft fronto-parietal area withmidline shift
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Epidural haematomaLucid interval
Associated fracture
laceration of middle meningealartery
Dont cross suture
Epidural VS Subdural
haematoma
1=84.22HU
EDH: typical lens shaped, 60-90HU
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EDHcross midline (1)
Braincontusion (2)
2
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Epidural VS Subdural
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Epidural VS Subdural
haematoma
Subduralhaematoma
generally more
largerCollection betweendura and arachnoid
Venous bleeding
May cross suturebut dont crossmidline
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Acute SDH: hyperdense
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IsodenseSDHSubacuteSubdural
haematoma
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Subacute SDH: isodense, +C needed
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Chronic SDH: hypodensity=CSF
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Case 4
50 years old womanWas found unconscious and sent toER
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Answer
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HyperdensityinSubarachnoidspace
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Description
CT brain without contrastNormal skull, orbit and paranasalsinuses
Hyperdensity lesion in the
subarachnoid space especially at leftsylvian fissure and basal cistern
Mild dilatation of the ventricularsystem
No midline shift
No clear abnormal hypodensity inthe brain parenchyma
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DiagnosisAcute subarachnoid haemorrhage
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CauseTraumatic
Aneurysmal bleeding
AVM
Extension from intraparenchymalbleed
UnknownPerimesencephalic cisterns(excellent outcome, negativeangiogram)
Subarachnoid haemorrhage
Subarachnoid
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Subarachnoid
haemorrhage
Non-contrast CT!!!
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Axial CT brain : before contrastinjection!!
C 5
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Case 5
50 years old man
Was found comatose and sent toER
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Answer
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Hyperdensitylesionin middleofpons
D i i
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DescriptionCT brain without contrast
Normal skull, orbit and paranasalsinuses
Hyperdensity lesion occupying middle
of pons with some local pressureeffect
Some hyperdensity lesion surroundingthe brainstem (subarachnoid blood)
(Normal ventricular size)
DiagnosisAcute pontine haemorrhage
Common sites of hypertensive
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Co o s tes o ype te s e
hemorrhage
Basal ganglia
Thalamus
Cerebellar
Pons
H d bl di MRI
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How do see bleeding on MRI
Depends on timing after hemorrhage
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Bleeding on MRI
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Bleeding on MRI
Biochem Stage Time T1W T2W
OxyHb in
RBCs
Hyperacute Hours Iso
DeoxyHb
in RBCs
Acute Hrs to
days
Iso,
MetHb in
RBCs
Early
subacute
Days
Extracell
MetHb
Subacute
to chronic
Days to
months
Ferritin
Hemoside
rin
Remote Days to
indefinite
Iso,
Hyperacute hematoma
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Hyperacute hematoma
T1W T2W
Acute hematoma
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Acute hematoma
T1W T2WProton
density
Early subacute hematoma
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Early subacute hematoma
CT T1W T2W
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Case 6
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Case 6
27 years old woman
30 weeks pregnant
Presented with headache andhemiparesis
InstructionDescribe the non-contrast CT
brainDiagnosis
Suggest further investigation toconfirm the diagnosis
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Answer
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Generalized
brainoedema
Hypodensity
lesionatrightparieto-occipital
area
Hyperdensitylesionattheposterior
partofsuperiorsagittalsinus
D i i
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DescriptionCT
brain without contrastNormal skull, orbit and paranasalsinuses
Hypodensity area at right perieto-
occipital areaHyperdensity lesion in posterior partof superior sagittal sinus
Generalized brain swelling
Obliteration of lateral ventricles
No midline shift
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DiagnosisSagittal venous sinus thrombosiswith venous infarction at rightparieto-occipital area
How to confirm thediagnosis
Cerebral angiogramMRV
CTV
Venous sinus thrombosis
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Venoussinusthrombosis
EmptyDeltaSign
Case 7
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Case 7
40 years old man
Weight loss for 6 months
Headache and confusion for 2weeks
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Answer
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Multiplering
enhancinglesion
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DescriptionMultiple ring-enhancing lesion,which appears hypersignal on T2Wwith surrounding oedema, at right
basal ganglia, left basal ganglia, bothcerebellar hemisphere
Mild dilatation of ventricles
No midline shift
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Case 8
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Case 8
40 year old woman
Presented with blurred vision
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Answer
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Pituitary mass
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DescriptionEnhancing mass at pituitary fossawith supra sellar extension
DiagnosisPituitary macroadenoma withsuprasellar extension
DDx Craniopharyngioma
Special thanks
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Special thanks
Dr. Chotipat Danchaivijitr
For these beautiful slides andimages