Selected Topics in Selected Topics in Rehabilitation and RadiologyRehabilitation and Radiology

Neuroimaging of CP Neuroimaging of CP Neuroimaging of MS, ADEM, GBSNeuroimaging of MS, ADEM, GBS

More on MRIMore on MRISome “rare birds” you can learn to recognizeSome “rare birds” you can learn to recognize

Osteopenia/OsteoporosisOsteopenia/OsteoporosisInterventional/GIInterventional/GI

Rehabilitation and RadiologyRehabilitation and RadiologyOBJECTIVESOBJECTIVES

Demystify/explain fancy new neuroimaging Demystify/explain fancy new neuroimaging techniques at a basic leveltechniques at a basic level

Get a few more board questions right Get a few more board questions right Choose well from available options, and Choose well from available options, and

know when to consult your radiologist know when to consult your radiologist Recognize and respect contraindications Recognize and respect contraindications Recognize limitations and appropriately Recognize limitations and appropriately

apply findings to patient management apply findings to patient management

Cerebral PalsyCerebral Palsy

Who remembers the definition? Who remembers the definition? Do they still have “idiopathic” as most Do they still have “idiopathic” as most

common etiology on the boards?common etiology on the boards?The most common etiologic sequence and The most common etiologic sequence and

result is _________________________?result is _________________________? Indications for neonatal imagingIndications for neonatal imaging

screening, therapeutics, prognostics, screening, therapeutics, prognostics, Indications for diagnostic imaging when Indications for diagnostic imaging when

they come to our clinicsthey come to our clinics

American Academy of Neurology American Academy of Neurology Practice Parameters Practice Parameters

Available on line – Available on line – http://www.aan.com/professionals/practice/ihttp://www.aan.com/professionals/practice/index.cfm?a=0&fc=1ndex.cfm?a=0&fc=1

Mar 2004Mar 2004Diagnostic Assessment of the Child with CeDiagnostic Assessment of the Child with Cerebral Palsyrebral Palsy

Jun 2002Jun 2002Neuroimaging of the NeonateNeuroimaging of the Neonate Sep 2003Sep 2003Utility of MRI in Suspected MS Utility of MRI in Suspected MS Jun 1993Jun 1993

Magnetic Resonance Imaging in the EvaluatMagnetic Resonance Imaging in the Evaluation of Low-Back Syndromeion of Low-Back Syndrome

Imaging of the NeonateImaging of the Neonate

Ultrasound on all < 30 weeks preterm infants Ultrasound on all < 30 weeks preterm infants once between 7-14 days, again between 36-40 once between 7-14 days, again between 36-40 weeksweeks MRI slightly better at picking up cystic white matter MRI slightly better at picking up cystic white matter

lesions lesions Will pick up IVH, PVL, ventriculomegalyWill pick up IVH, PVL, ventriculomegaly

Non-contrast CT for sick term babiesNon-contrast CT for sick term babies MRI between days 2-8 if not conclusive; diffusion MRI between days 2-8 if not conclusive; diffusion

weighted if availableweighted if available Pick up major hemorrhages, BG/thalamicPick up major hemorrhages, BG/thalamic Research on MRS promisingResearch on MRS promising

Imaging for Cerebral PalsyImaging for Cerebral Palsy

Get MRI if etiology not clearly establishedGet MRI if etiology not clearly established. . Genetic and metabolic testing if:Genetic and metabolic testing if:

Positive clinical findings (dysmorphology)Positive clinical findings (dysmorphology) Specific brain malformationsSpecific brain malformations Normal brain structurally and deterioration, episodic Normal brain structurally and deterioration, episodic

nature, + FH, no etiologynature, + FH, no etiology

Skip the EEG unless possible seizuresSkip the EEG unless possible seizures Check hearing, vision, nutrition, cognition, speechCheck hearing, vision, nutrition, cognition, speech Consider coagulopathy workup for early CVAConsider coagulopathy workup for early CVA

Myelination – Delayed vs abnormalMyelination – Delayed vs abnormal(PVL vs leukodystrophy)(PVL vs leukodystrophy)

Hypoplasia Corpus Callosum + Hypoplasia Corpus Callosum + Septo-Optic Dysplasia (mild)Septo-Optic Dysplasia (mild)

Hypoplasia Corpus Callosum + Hypoplasia Corpus Callosum + Septo-Optic Dysplasia (mild)Septo-Optic Dysplasia (mild)

Vermian and CC hypoplasia Vermian and CC hypoplasia Term baby, smart, bulbar-CP like pictureTerm baby, smart, bulbar-CP like picture

Metabolic errors – Agenesis CCMetabolic errors – Agenesis CC

Amino acid Amino acid non-ketotic hyperglycinemianon-ketotic hyperglycinemia

glycine synthaseglycine synthase

maternal phenylketonuriamaternal phenylketonuria methyl malonic acidemiamethyl malonic acidemia

MitochondrialMitochondrial pyruvate dehydrogenase pyruvate dehydrogenase pyruvate decarboxylase pyruvate decarboxylase fumarase fumarase

Organic AcidOrganic Acid glutaric acidemiaglutaric acidemia congenital disorder of congenital disorder of

glycosylationglycosylation 3-hydroxyisobutyric 3-hydroxyisobutyric

aciduriaaciduria

Peroxisomal Peroxisomal Zellweger Zellweger Refsum Refsum adrenoleukodystrophyadrenoleukodystrophy

Metabolic errors - CerebellarMetabolic errors - Cerebellar Menkes syndromeMenkes syndrome Smith-Lemli-Opitz Smith-Lemli-Opitz

syndromesyndrome Shapiro syndromeShapiro syndrome fetal alcohol syndromefetal alcohol syndrome acrocallosal acrocallosal ectodermal dyplasiaectodermal dyplasia Lhermitte Duclos Disease Lhermitte Duclos Disease

(PTEN mutations)(PTEN mutations) Pontocerebellar Pontocerebellar

hypoplasiahypoplasia

CGDS - congenital CGDS - congenital glycosylation defect, glycosylation defect, (carbohydrate-deficient (carbohydrate-deficient transferrin)transferrin)

JoubertJoubert recessive, several genes recessive, several genes

discovereddiscovered hypotoniahypotonia episodic hyperpnea/apneaepisodic hyperpnea/apnea abnormal eye movementsabnormal eye movements facial, other dysmorphisms.facial, other dysmorphisms. developmental delay developmental delay cerebellar ataxia cerebellar ataxia

Glutaryl-CoA dehydrogenase Glutaryl-CoA dehydrogenase deficiency deficiency

encephalopathic crises encephalopathic crises extrapyramidal symptomsextrapyramidal symptomsTreatment:Treatment:

Glucose/electrolyte IV for acute illnessGlucose/electrolyte IV for acute illness Carnitine supplementationCarnitine supplementation Low protein, lysine restricted dietLow protein, lysine restricted diet

Neuroimaging: Neuroimaging: frontotemporal and basal ganglia atrophyfrontotemporal and basal ganglia atrophy subependymal pseudocystssubependymal pseudocysts delayed myelinationdelayed myelination chronic subdural effusions and hematomas chronic subdural effusions and hematomas

Could be msitaken for child abuseCould be msitaken for child abuse

Other associationsOther associations

HIE, NEC, sepsis with either CC or vermian HIE, NEC, sepsis with either CC or vermian Congenital infections with cerebellarCongenital infections with cerebellar

ToxoplasmosisToxoplasmosis RubellaRubella

Dandy-Walker and variantsDandy-Walker and variants Chromosomal - trisomy 8, 13, 18, 21Chromosomal - trisomy 8, 13, 18, 21 Peroxisomal disorders and fatty acid oxidation Peroxisomal disorders and fatty acid oxidation

defects can produce migration defectsdefects can produce migration defects Folate and neural tube defectsFolate and neural tube defects

HIE vs MetabolicHIE vs Metabolic HIE - end of term gestation -HIE - end of term gestation -

hyperintense signal, atrophy of hyperintense signal, atrophy of putamen and thalamus, associated putamen and thalamus, associated with static esxtrapyramidal CPwith static esxtrapyramidal CP

Signal abnormalities, atrophy in the Signal abnormalities, atrophy in the putamen, globus pallidus, or putamen, globus pallidus, or caudate associated with genetic-caudate associated with genetic-metabolic diseasesmetabolic diseases

J Pediatr. 1997 Aug;131(2):240-5, "Brain J Pediatr. 1997 Aug;131(2):240-5, "Brain magnetic resonance imaging in suspected magnetic resonance imaging in suspected extrapyramidal cerebral palsy: observations extrapyramidal cerebral palsy: observations in distinguishing genetic-metabolic from in distinguishing genetic-metabolic from acquired causes," Hoon AH Jr, Reinhardt acquired causes," Hoon AH Jr, Reinhardt EM, Kelley RI, Breiter SN, Morton DH, EM, Kelley RI, Breiter SN, Morton DH, Naidu SB, Johnston MV.Naidu SB, Johnston MV.

Migrational DefectsMigrational Defects LissencephalyLissencephaly Microgyria Microgyria

PachygyriaPachygyria SchizencephalySchizencephaly

BOTTOM LINEBOTTOM LINE

Brain malformations can be caused by Brain malformations can be caused by environmental or genetic factors, by creating a environmental or genetic factors, by creating a toxic or energy-deficient intrauterine milieu, toxic or energy-deficient intrauterine milieu, changes in membrane function, or disturbing changes in membrane function, or disturbing normal expression of genes responsible for normal expression of genes responsible for morphogenesismorphogenesis..

Refer for detailed workupRefer for detailed workupRefer urgently if having episodic or step-Refer urgently if having episodic or step-

wise deterioration with/without illnesswise deterioration with/without illnessLater referral may not be helpfulLater referral may not be helpful

Imaging of Neuro-Immunologic Imaging of Neuro-Immunologic DisordersDisorders

MSMSADEMADEMTransverse myelitisTransverse myelitisGBS and variantsGBS and variants

[question = “What are several conditions that [question = “What are several conditions that MRI is almost always the best study for?”]MRI is almost always the best study for?”]

Multiple SclerosisMultiple Sclerosis

Ideal criteria – 2 attacks, 2 lesionsIdeal criteria – 2 attacks, 2 lesions May not fit primary progressive types versus May not fit primary progressive types versus

remitting-relapsingremitting-relapsing If fewer of either, look for corroboration with CSF If fewer of either, look for corroboration with CSF

and/or VEP studiesand/or VEP studies Poser, McDonald, newer criteriaPoser, McDonald, newer criteria

Location of lesionsLocation of lesions Differential gadolinium enhancementDifferential gadolinium enhancement

Differential: ADEM, CVD, HIV, sarcoidDifferential: ADEM, CVD, HIV, sarcoid Easy differential: Chiari I, cervical SCIEasy differential: Chiari I, cervical SCI

T2, gadolinium enhancementT2, gadolinium enhancementhttp://www.med.ege.edu.tr/norolbil/2000/NBD12600.htmlhttp://www.med.ege.edu.tr/norolbil/2000/NBD12600.html

http://www.annalsofian.orghttp://www.annalsofian.org

Representative axial T2- (upper left), Representative axial T2- (upper left), noncontrast T1- (upper middle), postcontrast noncontrast T1- (upper middle), postcontrast

T1- (upper right), and fast fluid-attenuated T1- (upper right), and fast fluid-attenuated inversion recovery (FLAIR) (bottom row)inversion recovery (FLAIR) (bottom row)

MRI variations you just sawMRI variations you just saw

FLAIR - special T2 sequence analysisFLAIR - special T2 sequence analysisFast Fluid Attenuation Inversion RecoveryFast Fluid Attenuation Inversion RecoveryCSF subtracted out, good for MS, PVLCSF subtracted out, good for MS, PVLMay enhance edges of ventricles as artifactMay enhance edges of ventricles as artifact

Gadolinium – MRI contrast material for T1Gadolinium – MRI contrast material for T1highly paramagnetic material highly paramagnetic material coordinates with protons of water molecules, coordinates with protons of water molecules,

changes them to a very bright signalchanges them to a very bright signal

More MRI variationsMore MRI variationsmanipulate slice, pulse orientation and manipulate slice, pulse orientation and timing, Te & Tr values, post-processingtiming, Te & Tr values, post-processing

Spin EchoSpin Echo Gradient EchoGradient Echo STIR short tau inversion recoverySTIR short tau inversion recovery TSHIRT TSHIRT Fast Spin EchoFast Spin Echo Time of Flight Angiography 2D & 3DTime of Flight Angiography 2D & 3D Fat Separation (Dixon – use for fractures)Fat Separation (Dixon – use for fractures) Diffusion Weighted Imaging (DWI)Diffusion Weighted Imaging (DWI) Echo Planar Imaging (EPI – use for FMRI) Echo Planar Imaging (EPI – use for FMRI) FMRI - BOLDFMRI - BOLD

MRS (MR Spectroscopy)MRS (MR Spectroscopy) Normal spectrum of eight metabolitesNormal spectrum of eight metabolites Reproducible, small filesReproducible, small files Peaks compared with creatinePeaks compared with creatine

NAA higher, myo-inositol halfNAA higher, myo-inositol half Multivoxel and 3D spectroscopyMultivoxel and 3D spectroscopy

Color map superimposed on diagnostic imageColor map superimposed on diagnostic image Region of interest down to 2-3 mm, 4-9 min.Region of interest down to 2-3 mm, 4-9 min. Works reliably only at long TEs, leaving NAA, creatine, Works reliably only at long TEs, leaving NAA, creatine,

choline, lipid, and lactate as others decaycholine, lipid, and lactate as others decay Gliomas (choline – cell membrane turnover)Gliomas (choline – cell membrane turnover) HIE (lactate)HIE (lactate) Dementia (low NAA, high myo-inositol)Dementia (low NAA, high myo-inositol)

CraniosynostosisCraniosynostosis

Post TBI with parietal fracturePost TBI with parietal fracture

Socially Responsive ChildSocially Responsive Child

OsteopeniaOsteopenia

Plain film – not quanititativePlain film – not quanititativeDEXA – newer versions may subtract DEXA – newer versions may subtract

hardware, contractures a problemhardware, contractures a problemUltrasound – very rough screeningUltrasound – very rough screeningQuantitative CT Quantitative CT Urinary N-telopeptideUrinary N-telopeptide

Teen with SMA and knee painTeen with SMA and knee pain

GI RadiologyGI Radiology

KUBKUBStool pattern, pneumatosisStool pattern, pneumatosis

Barium study – upper, SBFT, lowerBarium study – upper, SBFT, lowerStructural anomaly, IBDStructural anomaly, IBD

Radionuclide – not as sensitive as pH Radionuclide – not as sensitive as pH probe but useful, quanititativeprobe but useful, quanititative

No study sensitive for gastritis, esophagitisNo study sensitive for gastritis, esophagitis

GI - InterventionalGI - Interventional

Continent cecostomyContinent cecostomyAnterograde enemaAnterograde enemaBrief admission, traningBrief admission, traning

Non-surgical tube placementNon-surgical tube placementNJ by fluoro in cases of SMANJ by fluoro in cases of SMAGJ – poor feeding tolerance via GTGJ – poor feeding tolerance via GTLimitations due to finer gauge tube – may not Limitations due to finer gauge tube – may not

be able to use crushed medsbe able to use crushed meds

SMA - obstruction SMA - obstruction