RADIO 250: ICC in Radiology and Nuclear Medicine

LEC 09: NEURORADIOLOGY

Exam 1 | Dr. Elepano | September 2, 2013
OUTLINE
I. Introduction
II. CT Scan
III. MRI
A. T1-Weighted Imaging
B. T2-Weighted Imaging
IV. Angiogram
V. Interventional Radiology

VI. Sample Cases

A. Case 1
B. Case 2
C. Case 3
D. Case 4
E. Case 5
F. Case 6

At the end of the lecture, you must know:

o The basic orientations
o The difference between a CT Scan and MRI, T1 and T2 images.

I. INTRODUCTION
Radiology is the branch of medical science dealing with the
medical uses of radiation devices and other forms of energy for
the purpose of obtaining visual information as part of medical
imaging.
Interventional Radiology is the performance of medical
procedures with the help of medical imaging.
A neuroradiologist is a radiologist who specializes in the use of xrays and other scanning devices for the diagnosis and treatment
of diseases of the nervous system
o Concerned with the clinical imaging, therapy, and basic science
of the central and peripheral nervous system.
o May include other parts of the body, such as the brain, spine,
neck, etc.
Neuroradiology is a rapidly advancing field of medicine
o Creation of stronger magnets to create clearer MR images of
the brain
The higher the Tesla of an MRI machine, the greater the
details seen on the images produced.
o You can also use MRI to show areas of blood flow in different
regions in the brain (functional MRI)

III. MRI
Magnetic Resonance Imaging a tool that uses magnetic fields
created by a giant magnet to produce three-dimensional images
of the human body.
Can be used even with pregnant patients because there is no
radiation.
Patient should be devoid of metallic objects pacemakers,
tattoos with metallic implants, piercings
The two most common types of MRI images are T1 and T2.
o T1 useful to look at normal anatomy of brain (water is dark)
o T2 useful to look at abnormal processes or pathology in the
brain (water is white)

A. T1-Weighted Imaging
In T1, fat is bright.
White matter (inner part of the brain) is brighter than gray matter
(cortex).
Water is dark.

Figure 2.T1-Weighted Imaging of the Brain.As you can see, the

white matter is brighter than the gray matter. The ventricles are
dark due to CSF being dark in T1.
B. T2-Weighted Imaging
In T2, water is bright.
Blood is bright if it is acute.
IB ID BD BB DD (isodense and bright earliest blood; isodense and
dark late acute; bright dark bright in t1 dark in t2 subacute;
bright bright; dark dark chronic)
White matter is darker than gray matter

Figure 1.Functional MRI.

Planes of Imaging
o Sagittal
o Coronal
o Axial most commonly used orientation
II. CT SCAN
Computed Tomography a complex machine that uses x-rays to
create three-dimensional images of the body
What is bright/dark on CT Scan?
o The denser the tissue, the brighter it looks on CT Scan.
o If the tissue is very thick, not much radiation will enter the
body, therefore it will look white.
o Any calcified structure like the skull appears bright.
o New hemorrhage in the brain is also bright (a lot of iron, very
dense)
o Water or CSF or even air looks dark on CT

PAULA, BUTCH, CLEMS, JEREEL

Figure 3.T2-Weighted Imaging.Compared to T1, the gray matter is

brighter than the white matter in T2. Also, CSF is bright which makes
the ventricles appear bright as well (WW2).
IV. ANGIOGRAM
Some neurologists just want to look at blood vessels in the brain
Insert a thin catheter through the femoral artery passing to the
abdominal aorta then the carotids, inject a contrast agent
(uniodinated dye) and then use x-rays to see the blood flowing
inside the artery

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LEC 09: NEURORADIOLOGY

Useful for visualizing aneurysms, vascular malformations (AVM

can cause headaches especially in the young), stenosis in the
vessel, etc.

across sutures unlike the epidural hemorrhage which do not cross

sutures
C. Case 3

V. INTERVENTIONAL RADIOLOGY
Uses x-rays and other imaging tools in the operating room to
perform minimally invasive surgery
o Involves high radiation doses for the radiologists
VI. SAMPLE CASES
A. Case 1

Figure 7.Another Case of Motorcycle Crash

Figure 4.Epidural Hemorrhage.This is a case of a 20-year-old woman

who was involved in a motorcycle crash. Note the presence of the
convex-shaped (lenticular) intracranial epidural hemorrhage (convex
shape does not exceed adjacent sutures)

Figure 8.CSF Fistula with Post-Traumatic CSF Rhinorrhea. This MRI

cisternography shows CSF fistula with post-traumatic CSF rhinorrhea
secondary to trauma from the motorcycle crash (rectangles). The
bright material is CSF so this is a T2-Weighted Imaging.
D. Case 4

Figure 5.Frontal Epidural Hemorrhage (EDH).EDH exists in the

potential space between the dura and the inner table of the skull. It
can cross the midline but cannot cross the cranial sutures where the
dura is more firmly attached.
B. Case 2

Figure 6.Subdural Hematoma. This is a case of a 25-year old man

who was involved in a motorcycle crash. Note the concave-shaped
(follows the contour of the brain) subdural hematoma on the right
side of the brain pushing the midline structures (herniations)
contralaterally. Also, this kind of hemorrhage can be seen to expand

PAULA, BUTCH, CLEMS, JEREEL

Figure 9. Hypertensive Bleed in the Brain. This is a case of a 65-year

old with hypertension and left hemiparesis. As seen in this image,
intracranial hemorrhage in the basal ganglia, together with the
clinical condition of the patient, points to a probable hypertensive
bleed (most common areas for hypertensive bleed: basal ganglia,
thalamus, and pons as seen on the image below). Note that on the
area adjacent to the lesions, there is a lucency which represents
edema. If the lesion is a tumor, the edema will be more florid as

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compared to that of a bleed. Moreover, the edema of a tumor will

have finger-like projections.

Figure 12.EmbolicStroke.This is a case of a man who presented with

right hemiparesis 6 hours PTA. Caudate nucleus and globus pallidus
on the left hemisphere are no longer distinct.

E. Case 5

Figure 13.Early Signs of MCA Infarct. Left: Hyperdense MCA Sign.

Right: Insular Ribbon Sign and Obscuration of the Lentiform Nucleus.

Figure 10.Subarachnoid Hemorrhage.This is a case of a patient who

presented with sudden onset of headache and alteration of
consciousness. Note the bright lesions that follow the contour
cisterns, sulci and gyri (rectangles). This is consistent with a
diagnosis of subarachnoid hemorrhage.

Figure 14.Acute MCA Infarction.There are usual patterns seen for

ACA, MCA and PCA infarction. The density on the image above on
the right hemisphere of the brain is consistent with an MCA infarct.
The region roughly bounded by the blue rectangle represents an
ACA infarct while the region roughly bounded by the red rectangle
represents a PCA infarct.
END OF TRANSCRIPTION

Figure 11.Subarachnoid Hemorrhage due to Ruptured ACoA

Aneurysm. Focal SAH or ICH is helpful in localizing the bleeding
source as in this case. Localized SAH in the anterior interhemispheric
fissure is most probably due to ruptured ACoA aneurysm.
F. Case 6

PAULA, BUTCH, CLEMS, JEREEL

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