BRAIN IMAGING

Interpretation of Brain CT and MRI

Angela Nelson, MSN, RN, CCRN,
ACNP-BC
Department of Neurosurgery
I have no current affiliation or financial arrangement with
any grantor or commercial interest that might have direct
interest in the subject matter of this CE Program
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Objectives
Identification of normal brain anatomy on
both CT and MRI imaging
Identification of common CNS
abnormalities on both CT and MRI
imaging
Identification of appropriate radiographic
studies to be obtained for the more
common suspected CNS abnormalities
Brain Anatomy
Layers covering the Brain
Skin
Periosteum
Bone Craniumepidural
space is between dura mater and
the bone. Superior Sagittal Sinus
lies here
Dura Mater hard mother
(leather like)
Subdural space lies between dura
and arachnoid
Arachnoid Membrane
spider (spider web)
Subarachnoid spaces lies
between the arachnoid and pia
Pia Gentle Mother(thin
layer adhering closely to brain)
Cerebrum
4 Lobes: Frontal, Temporal, Parietal and
Occipital
Falx Cerebri Separates the 2 hemispheres
Tentorium Cerebelli Separates the cerebellum
from the Cerebrum
Gyri Rounded ridges on surface of brain
Sulci Shallow groves separating the gyri
Fissure Deeper groves
Gray Matter Unmylinated Nerve Fibers
White Matter Mylinated Nerve Fibers
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Review of Lobes
Frontal-Personality, judgment, abstract
reasoning, social behavior, language
expression and movement
Temporal-Hearing, language expression,
storage and recall of memory
Parietal-Interprets and Integrates
sensations including pain, temperature,
touch, size, shape, distance and texture
Occipital-Interprets visual stimuli
Right and Left-Cerebral Hemispheres
connected by Corpus Collosum
Right
Emotion
Prosopagnosia
Music
Spatial Relationship
Left
Logic Brain
Speech
Math
Science
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Falx Cerebri
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Primitive Structures Beneath the Cerebrum.
. . .
Diencephalon-Thalmus/Hypothalmus/RAS/Internal Capsule
Thalmus
Relays sensory stimuli to cerebral cortex
Primitive awareness of pain
Screening of incoming stimuli and focusing of attention
Hypothalmus
Controls body temperature, appetite, water balance, pituitary
secretions, emotions and autonomic functions including sleep and
wake cycles
Internal Capsule Motor Tracts
Limbic SystemInitiating basic drives; hunger, aggression, emotional
and sexual arousal
Reticular Activating System
Arousal, Sleep and Wakefulness
Screens all incoming sensory information
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Basal Ganglia
Corpus StriatumCaudate Nucleus
Lentiform Nucleus Putamen and Globus
Pallidus
Interconnected nuclear masses deep
within cerebral hemispheres involved in
the initiation of voluntary movements,
controls of postural adjustments
associated with voluntary movements
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White/Gray Matter
White Matter
Consists mostly of
myelinated axons
(surrounded by a fatty
sheath containing
myelin) that connect
various gray areas of
the brain to each
other
Gray Matter
Contains cell bodies as
well as fibers of
unmylinated neurons
Gray matter includes the
basal ganglia (caudate
nucleus, putamine,
globus pallidus),
thalmus, hypothalmus,
subthalmus, and
cerebellar nuclei
Cerebellum
Maintains muscle tone, coordinate muscle
movement and controls balance
A disorder of this area may cause
dizziness, nausea, balance and
coordination problems
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Cerebellum
Brain Stem
Composed of Medulla Oblongato, Pons, and
Midbrain
Medulla Autonomic Function (HR, RR, BP)
Pons Arousal
Respiratory
Midbrain Controls sensory response
Produces autonomic behavior necessary for
survival
Pathways for nerve fibers between higher and
lower neural centers
Origin for 10 of 12 pairs of cranial nerves
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Medulla
Pons
Ventricular System
Contains the CSF
Composed of lateral ventricles, foramina
of Monro, the third ventricle, aqueduct of
Sylvius, and the forth ventricle
Choroid Plexus located throughout the
system makes the CSF
CSF leaves the ventricles through the
foramina of Magendie and Lushka to
reach the subarachnoid space
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Lateral Ventricles
Foramen of Monroe
Third Ventricle
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Aquaduct of Sylvius
4
th
Ventricle
Cerebral Circulation
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Cerebral Circulation
MR Angiography
Internal Carotid Artery
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Middle Cerebral Artery
Anterior Cerebral Artery
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Venous Drainage
Venous Sinus Drainage
MR Venography
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Computed Tomography
Nobel Prize Winner Sir Godfrey Hounsfield
developed CT for clinical use in 1972-1973
The first company to introduce the CT
scanner was EMI (English Musical
Instruments)-the same company that
distributed the Beatles on the Apple label
Grossman, R.I. and Yousem, D.M. The Requistes. Neuroradiology. Second Edition. Philadelphia, PA,
2003
Computed Tomography Physics
Uses a highly collimated x-ray beam
Photons that pass through the patient are
collected by CT detectors which show a
differential rate of intensity on a gray scale
The beam is rotated across the patient at many
angles so as to get a differential rate of
absorption
Grossman, R.I. and Yousen, D.M. The Requistes. Neuroradiology. Second Edition, Philadelphia, PA, 2003
Indications of Use of CT
First line in evaluation of a change in mental status
Test of choice for those with implantable devices
Shows acute and sub acute blood (ICH/SAH, SDH)
Bony abnormalities, i.e. Trauma or fracture
Edema/Mass effect
Abnormalities in size and shape of structures
i.e. brain tissue atrophy, gyri effacement with swelling
Hydrocephalus
Hemorrhagic stroke
Add contrast if looking for tumor, abscess, or cerebral
arteries and veins
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Disadvantages of Computer Tomography
Poor imaging for demyelinating disease
Poor resolution in the posterior fossa of
the brain primarily due to streak artifact
from the bones
Density gradients on CT
Bone
Calcification
Contrast material
Clotted blood
Some tumors with densely packed cells
Grey matter
White matter
Edema
Pus
Necrotic Cavities
CSF
Fat Air
How things appear on a CT?
Acute Blood/Calcifications-White
Chronic Blood Collection-Low density black to
gray as increasing density
CSF/Air-Black
White Matter-Less dense than gray matter and
therefore will be darker
Ischemia-Lower density and therefore will be
darker and may not appear for 12 hours
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Radiographic Images
What is on the left
side of the picture
represents the right
side of the patients
brain
Axial-top to bottom or
bottom to top
Radiographic Images
Sagittal-Side to side
T1
Radiographic Imaging
Coronal-Front to back
or back to front
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Orbit
Spenoid
Temporal
Mastoid Air
Auditory
Cerebellum
Frontal Lobe
SylvianFissure
Temporal Lobe
Supracellar Cistern
Midbrain
4th Ventricle
Cerebellum
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FalxCerebri
Frontal Lobe
Anterior Horn
3rd Ventricle
Quadrigeminal Cistern
Cerebellum
Radiology Atlas.exe
Caudate
Ant HornLat Ventricle
Internal Capsule
Putamen/Globus Pallidus
3rd Ventricle
Quadrigeminal Cistern
Vermis
Occipital Lobe
FalxCerebri
Frontal Lobe
Bodyof Lateral Ventricles
Corpus Callosum
Parietal Lobe
Occipital Lobe
Superior Sagittal Sinus
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FalxCerebri
Superior Sagittal Sinus
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How to Approach a Read
View the Subdural windows for bony
defects, fractures
Are the sinuses opacified
Bony Windows
Soft Tissues (brain window)
View the lateral, 3
rd
and 4
th
ventricles
Are they enlarged, compressed, distorted,
diplaced
Is there anything in them other than
choroid plexus
Look for blood or debris especially in the
dependent portions
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Brain Window
Is there a focal density abnormality in the
brain?
Is there something that is not
symmetrical?
Is it mass producing or volume losing?
Are midline structures midline?
Are the sulci symmetrical or effaced?
Are the lateral ventricles symmetrical?
Brain Window
Is the gray/white junction seen around
both cerebral hemispheres?
Is the insular ribbon seen?
Are the basal ganglia distinct from the
internal and external capsule?
Spinal Cord
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Sinuses
Orbits
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External
Auditory
Canal
Mastoid
Air Cells
Medulla
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Cerebellum
Temporal
Lobe
4
th
Ventricle
4
th
Ventricle
Basilar Artery
Pons
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Basilar Artery
Supracellar Cistern
Sylvian Fiisure
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Frontal Lobe
Parietal Lobe
Quadgeminal
Cistern
Anterior Horn
Lateral Ventricle
Third Ventricle
Vermis of
Cerebellum
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Occipital
Horns
Occipital Horns
Caudate Head
Choroid Plexus
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Body of Lateral Ventricles
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White Matter
Faux Cerebri
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Central Sulcus
Pre Central Gyrus
Post Central Gyrus
Intraparietal Sulcus
Cental Sulcus
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Hemorrhagic Contusion
Often due to impaction of
the brain against the skull
on the opposite side of
the injury
Contusion in the right
frontal lobe with
surrounding low density
infarction or edema
CT
Chronic Subdural Hematoma
Note the left sided low
density collection of
this chronic subdural
hematoma
CT
Acute Subdural Hematoma/CT
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Meningioma/CT
Epidural Hematoma/CT
Glioblastoma/CT
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Hypertensive Cerebellar Bleed/CT
Coagulopathic Bleed/CT
Chronic Subdural Hematoma/CT
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MCA Infarction/CT
Melanoma
Hydrocephalus
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Indications for Use of MRI
Use with caution with people with claustrophobia,
implantable devices or programmable shunts
Provides better soft tissue differentiation than CT
Tumors
Abscess
Vascular Anomalies of the Brain
Stroke
Trauma
Chronic Central Nervous System Disorders
Stereotactic Surgical Planning
MRI Sequences
Diffusion
Magnectic Susceptibility (gradient echo,
hemoflash) Blood, calcium and calcified lesions
Flair (Fluid Attenuation Inversion Recovery)
Good at identifying abnormalities adjacent to
CSF
T1
T1 Post
T2
Types of MRI
Gadolinium Enhancement-Tumor/Infection/Inflammation
T1T2-Vascular structures appear brighter on T1 and darker on T2
Diffusion (DWI)-Can assess an acute infarct within the last 2 weeks
MRV-Assess patency, stenosis or occlusion of the venous system
MRA-Assess patency, stenosis or occlusion of arterial system and vascular
malformations. Multiple viewing angles
Flair/Echo Gradient-Similar studies however an echo gradient may see a
smaller bleed clearer. Flair can improve image quality of lesions adjacent to
CSF
Functional MRI-Asked to do sensory, motor and cognitive tasks. Shows
increasing signals with cerebral
activity
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Diffusion MRI
Diffusion Weighted Imaging (DWI)
Determines the ease of water diffusion
Can determine cerebral ischemia within minutes
of irreversible damage
Most sensitive way of determining an acute
infarction
Good in differentiating vasogenic edema
(generally tracks along white matter and spares
the gray matter)
Appears as dark CSF, bright Fat and Lesions
DWI
Apparent Diffusion Coefficient (ADC)
Measures the brownian motion of protons
High ADC will be seen in CSF where there
protons can freely move
Low ADC will be found with new strokes
and tumors where they are more tightly
packed together
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T1 Pre and Post contrast
CSF appears black
Subcutaneous tissue
(beneath the skull)
appears white
Blood appears white
White matter brighter
than gray matter
Lesion will appear dark
Shows blood clearer
*Note-T1 post-
sinus/nasal terbinates,
choroid plexus bright
T2 MRI
CSF appears white
Subcutaneous tissue
appears black
Blood appear white
White matter darker than
gray matter
Shows older changes and
microvascular
More accurate for brain
pathology
Flair/Echo Gradient
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Tonsils
Vertebral Artery
Falx Cerebelli
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Vermis
Medulla, Verebral Artery, 4 th ventricle
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Subarachnoid Hemmorhage
Primary causes include Aneurysm, AVM and
head trauma
Worst headacheof my life
30% survive without major disability
Outcome is associated with neurological status
at time of Presentation
10-30 % die before getting medical attention
SAH/CT
SAH/CT with contrast
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Diffuse Axonal Injury
Frequent result of traumatic deceleration injuries
resulting in shearing of axons and small blood
vessels
Frequent cause of persistent vegetative state
Usually occur at gray/white matter junction
DAI suggestive in any pt who demonstrates
clinical symptoms disproportionate to imaging
findings
Up to 90% of these patients remain in a
persistent vegetative state, rarely die
DAI/Diffusion
Glioblastoma
Average age of diagnosis 50-70
Occur more commonly in men
Most patients die within 8-18 months
Clinical presentation depends on location
of the tumor; stroke like symptoms, focal
neurological deficits, headache, change in
behavior, seizure
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GBM/T1/T2
Meniogioma
15% of all brain tumors
More common in women
Usually occur in 3
rd
to 6
th
decade of life
Discrete well defined dural masses
Can remain clinically asymptomatic for years as
they grow slow
Common symptoms include focal defecits,
seizures, headaches and psycho organic
syndrome
Meningioma/T1/T2
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STROKE
CT is preferred for intracranial
hemmorhage
For non hemorrhagic stroke a CT can be
negative for 24-36 hours
Flair/T2 MRI can detect in 6-12 hours
Diffusion MRI can detect within minutes
STROKE/Ct/T1
T1
T2
Flair
DWI
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Metastatic Tumor
66 year old right
handed female with
PMH mestatic lung
cancer, s/p Right
Lobectomy with
radiation and Right
masectomy
1-2 months of slurred
speech, word finding
difficulty and lethargy
Exam:
Mild right upper
extremity drift, mild
right dysmetria
Found to have left
temporal lesions
Patient started on
Anti-convulsants and
lesion resected
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Post op
Blood products and air
Skull Based Meniogioma
61 year old, left handed male
with PMH of HTN, A fib (on
coumadin), and
Hypercholesterolemia
3 week history of worsening
vision and sinus headaches
with he attributed to his
sinuses
Initially sent by his cardiologist
to an Optomotrist, then
Opthomologist and finally a
Neuroopthomologist who
prompty admitted him
Stated on IV steroids on
admission and anti-
convulsants
INR on admission 3.59. Given
FFP and Vitamin K
Exam remarkable for Right
Homonymous, left eye 20/200
and right unable to visualize
anything but the chart
Tumor measured 5.4 x 4.8 cm
extending into the optic canals
and suprasellar cistern
Taken to OR 2 days after
admission after INR <1.4 for a
Bifrontal Craniotomy
Pre Op
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Presumed Metastatic Lesions
72 year old right handed male
with Prior history of CABG,
AAA, Cardiac Stent, and
recently Mylodysplastic
Syndrome with a 4 day history
of dizziness and headaches,
now with confusion and
receptive and expressive
dysphagia
Exam significant for right sided
weakness, right drift, right
facial droop, inability to follow
commands
Anticonvulsants and IV
steroids initiated
Platelet count 6
Hematology consult-found to
have high grade Mylodysplasia
Transfused multiple units of
platelets in an attempt to >150
before OR
Patient developed Aspiration
Pneumonia and surgery was
delayed
Continued to deteriorate
CT Hemmorhagic Lesion
Large Left MCA Infarction
58 year old man with
history of tobacco
use, HTN, BPH who
was in process or
being worked up for a
transient decreased
sensation in right arm
At work with sudden
right sided weakness,
right facial droop and
aphasia
Found to have
occulsion of the left
internal carotid artery
and M1 segment left
MCA thrombus
Given TPA without
improvement
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Pituitary Macroadenoma
39 year old right
handed male with no
PMH.
Developed fatigue 3
years ago, treated for
depression, started
on Lexapro
Past 2 years noted a
decrease in the
amount of facial and
leg hair
Low testostone, Low
LH
Visual fields normal
2.2 cm tumor
Underwent
Endoscopic TSSH
approach Resection
of Mass
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Pituitary Tumor/Normal Pituitary
Glioblastoma
48 year old right handed man with
no PMH
8 week history of congestion,
head feeling heavy and full
Began to develop nausea/vomiting
with headaches 3-4 times per day
Treated with 2 courses of
antibiotics and steroids for
presumed sinusitis
Symptoms improved with steroids
but then returned when tapered off
Treated with Maxol for migranes
ENT with negative CT of Sinuses
Finally MRI with large right
temporal lesion
Stated on IV Steroids and
Anticonvulsants
Exam grossly intact
Underwent Craniotomy for
Removal Of Lesion
Now undergoing radiation and
chemotherpy for an aggressive
growing lesion
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Mystery Lesions
49 year old right handed
male with PMH of HIV,
AIDS, and Stoke presents
with a 3 week history of
headaches particularly
severe for the last 3 days
Exam significant for
dysarthric speech,
bilateral dysmetria, left
foot drop
Patient underwent
craniotomy with
pathology sent however
no cultures were sent.
Path inconclusive
Pathology inconclusive
Lesions/Old Infarctions
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Arteriovenous Malformation
21 year old right handed male
presents with an acute onset
on BLE numbness
Had a warm sensation
throughout his body, felt dizzy
and faint with a headache
which progressed to complete
left sided weakness
Exam significant for left sided
weakness although A/O x3
Angiogram Right frontal AVM
Underwent pre op
Angio/Embolization of Lesion
AVM resected with post op
Angio done
POD #6 developed
headaches and CT revealed
right frontal epidural hematoma
and pt emergently taken to OR
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Acute Cerebral Infarction of Pre-Central
Gyrus
63 year old right
handed, male with
sudden onset of
tingling in right check,
inability to speak and
could not properly use
right hand
T2 Acute Infarction
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Communicating Hydrocephalus
CSF circulation
blocked at level of
arachnoid
granulations
Multiple Sclerosis/Flair
Age of onset 10-59, with
peak between 20-40
Demyelinating disease of
white matter affecting the
cerebrum, optic nerves
and spinal cord
Typically has
exacerbations and
remissions
Common symptoms
visual disturbances,
spastic paraparesis and
bladder dysturbances
Infarction with Hemicraniectomy
Pre op Post op
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Trauma
Subdural
Intraparenchymal
SAH
Epidural
Cerebellar Hemangioblastoma
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DWI
Infarction
ADC
Melonoma withhemmorhage
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Angela.Nelson@nyumc.org
http://www.imaios.com/en/e-Anatomy/Brain-
neuroanatomy-MR
http://www.med.harvard.edu/AANLIB/home.htm
http://www.healthsystem.virginia.edu/courses/ra
d/headct/index.html
http://brighamrad.harvard.edu/cgi-bin/rc-
report/query.py
http://spinwarp.ucsd.edu/NeuroWeb/Anatomy/br
ain/brain-anat.html
http://www.strokecenter.org/images/
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