Tumors and Vascular

diseases of the Brain

April 3, 2008

Jennifer Villa Frabizzio,

M.D.

Abington Memorial Hospital

Radiology Group of Abington, PC
Board Certified in Diagnostic
Imaging with Added Qualifications
in Neuroradiology

Topics for Discussion

Neuroimaging
Then and Now
Neuroanatomy
Vascular and Nonvascular
Vascular Disorders
Diagnosis and Treatment
Tumors
Primary and Metastatic Disease

Neuroimaging- Then
Standard Radiograph
Pneumoencephalography
Direct Cerebral Angiography

Pneumoencephalograh
y

Introduced in 1919 by American Surgeon

Dandy Walker
Primary method of Neurodiagnosis used late
until late 1970s early 1980s
Lumbar puncture performed in sitting position
Patient placed in somersault chair with head
suspended in harness
CSF removed and 10-15 mls of air introduced
Patient is tilted upside down and 50-60 mls
more air introduced

Pneumonecephalograp
hy cont.

Air outlined brainstem structures and supra

tentorial structures to diagnose masses,
tumors and cerebral atrophy
Very time consuming, could take from one to
two hours to perform
Following the procedure patients invariably
developed severe headache and maybe a fever
Sampling of CSF post procedure showed high
protein and white blood cells, which seemed to
be a response to the air
Symptoms would usually resolve within 48hrs

Direct Cerebral
Arteriography

Pioneered in 1927 by Dr. Egas Moniz

Needle was inserted directly into the
common carotid artery in the neck and
contrast material injected
Rapid series of radiographs were taken
of the skull in numerous projections
Currently studies are preformed by
inserting a catheter into the femoral
artery
Remains as gold standard for imaging
arterial and venous structures

Neuroimaging-Now

Computed Axial Tomography

CAT SCAN

Magnetic Resonance Imaging

MRI

Computed Tomography

From Greek tomos (slice) and graphein (to write)

Generation of three dimensional images for a series of
two dimension Xrays taken around a single axis of
rotation
Computer generated images produce an axial image
Early CT scans in early 1970s had single slice,
allowing imaging of the brain in four minutes
Modern state of the art scanners can have up to 200
slices and can image the whole body in 30 seconds
Iodine base contrast material in injected in an arm
vein to optimize visualization of vessels and solid
organs
Uses ionizing radiation to obtain images, and should
be used with caution in pregnant or pediatric patients

CT cont.

Advanced techniques
CT angiography and venography
Contrast rapidly injected into an arm vein and timed to
visualize arteries and veins
Has become first line minimally invasive procedure to
image the intracerebral vasculature and coronary
arteries

CT perfusion
Rapid imaging of the brain after contrast injection
followed by computer post processing can generated
area in the brain at risk for stroke

Magnetic Resonance
Imaging (MRI)

Powerful magnetic field used to align hydrogen atoms

in the body
Radiowaves are activated that alter the alignment of
this magnetization, allow for the atoms to relax at
different rates according to their chemical composition
These signals are manipulated to reconstruct images
of the body
Greater soft tissue contrast than CT
No ionizing radiation
Must be extremely careful to remove all metal from
patients
Contraindicated in patients with pacemakers

MRI cont.

Advanced techniques
MR Angiography
detection of moving molecules done without
the injection of contrast to visualize flowing
blood
excellent to visualize head and neck vessels
Gadolinium based contrast agent is injected
into an arm vein, mixed with flowing blood
and allows for visualization of vessels
especially in the chest and abdomen

MRI cont.

Diffusion imaging

For visualization of acute stroke, damaged

cells swell and cause restricted diffusion

MR spectroscopy

Separating the chemical composition of

brain lesions into different peaks to
determine chemical composition

Functional MRI

Using changes in blood flow to monitor

neural activity

Neuroimaging
Nonvascular

Neuroimaging
Vascular

Vascular diseases
Stroke
Trauma/Intracranial Hemorrhage
Aneurysm
Arteriovenous Malformations

Stroke

Acute episode leading to a

neurologic deficit
80% are due to ischemia (either
thrombotic or embolic)
20% other

Transient ischemic attack (TIA)

Focal events that resolve in 24hrs

Stroke cont.

Of the 80%, three quarters are due to

atherosclerotic disease or occlusion of
vessels.
Diagnosis can be made by both CT and MRI,
as well as the advanced images techniques
MRI is more sensitive, it can age strokes and can
detect an acute stroke within thirty minutes.
CAT scan can detect a stroke within 6 hrs, and is
useful to determine if there is underlying
hemorrhage

71 year old white

female
Found by husband in the bathroom on
the floor, unable to move left side of her
body
Brought by EMS to AMH and had a CAT
scan

Cont.

Admitted to intensive care

CAT scan performed 6 hrs later
after worsening of symptoms

Cont.

Patient continues to deteriorate,

despite supportive measures
CAT scan performed 24 hrs after
admission

No improvement
CAT scan performed 12 hrs later,
48 hrs after admission

19 year old white male

Found unconscious in dorm room

by roommate after drinking all
night at a fraternity party
Friends had seen him take some
pills, found later to be valium
(benzodiazepine-tranquilizer)

Anoxic brain injury

Lack of blood flow to the brain

affects deep grey matter
structures and can cause
irreversible damage
Can also be seen in near
drowning, carbon monoxide
poisoning

Intracranial
Hemorrhage

Non Traumatic

Hypertension (most common)

Tumor
other

Traumatic
Epidural and subdural Hematomas
Hemorrhagic contusions

Hemorrhage cont.

Hypertensive type most common

in small arteries off of the middle
cerebral artery
High mortality depending on size
and location

81 year old black male

Found at breakfast with difficulty

speaking
Brought to AMH by son
Ran out of blood pressure
medicine last week
Vital signs in ER
Blood pressure 210/80
CAT scan upon arrival

Cont.

ICU Staff was unable to control

blood pressure, symptoms
worsened

Hemorrhage cont.

Traumatic
Subdural hematomas
Common in the elderly or in children
due to child abuse
Tearing of bridging veins along the edge
of the brain
Can grow large and may need
neurosurgical evacuation

Hemorrhage cont.

Epidural hematoma
Mostly due to injury to the middle
meningeal artery, superficial vessel
that runs along the skull
Commonly associated with skull
fractures
Large ones are neurosurgical
emergencies

Aneurysms

Most common type is the berry or

saccular aneurysm

Are usually congenital or degenerative

Focal outpouching of a artery
Occur in specific locations along the Circle
of Willis
Once diagnosed, the risk of rupture is
1.3% per year
A ruptured aneurysm requires urgent
diagnosis and treatment, due to a high risk
of rebleeding and 50% mortality

Aneurysms cont.

Patients present with worst

headache of life and can have
varying stages of consciousness
CAT scan of the brain show
diffuse subarachoid hemorrhage,
crab of death

Aneurysms cont.

Treatment
Conventional-crainiotomy and
aneurysm clipping
Neurointerventional-intravascular
coiling

Arteriovenous
Malformations (AVM)

Network of arteries connected directly

to veins with no intervening brain
tissue or capillaries
Can hemorrhage because of high flow
state
Treatment

Endovascular coiling
Glue
Stereotactic Radiosurgery

58 year old female

MVA, crashed car into a tree

because she blacked out
Arrives at AMH with headache,
bruising but awake
CAT scan performed

Brain Tumors

Primary brain tumors are 70% of all

intracranial neoplasms
The remaining 30% represent
metastases from primary tumors
elsewhere in the body, common
ones include lung and breast
cancer
MRI with Gadolinium in the
modality of choice for diagnosis

Brain tumors cont.

Primary Brain Tumors

80% are gliomas, the most aggressive
is the Gliomblastoma Multiforme
(GBM)
20% are all others, which include
meningiomas from the brain surface,
nerve sheath tumors and lymphoma
Treatment is a combination of
surgery, radiation and chemotherapy

Thank you
.

jvfrabizzio@amh.org
.