NEURORADIOLOGY

dr. Dhanti Erma, Sp.Rad

NEURORADIOLOGY (NEUROIMAGING)

 Plain Film
 CT Scan (Computed tomography)
 MRI (Magnetic Resonance Imaging)
 Angiography / DSA (Digital
Subtraction Angiography)
 Sonography / USG / Color Doppler
 Nuclear Medicine
Skull X-Ray
Projection :
•Postero-Anterior (PA) in varies angle
•Antero-Posterior (AP)
•Right or Left Lateral
•Basis Cranium
•Other special photos :
Paranasal Sinus,
Sellar photo
Skull X-Ray
Assess 
1. Skull bone
•external tabulae
•intenal tabulae
•diploe
•digital markings
In meningioma : endostosis or
protrusion into internal tabulae
2. Sutures : sagital, coronary, lambdoid
Children : have not closed completely
 Synostosis : sutures close in earlier time
Space Occupying Process : widening
sutures
3. Sella tursica :
•Sellar tubercle
•Dorsum of sellae
•Anterior and posterior clinoid process
In chronic increased ICP destruction of
sellae : thinning of the dorsum first
Hypophyseal tumour : ballooning sellae
4. Temporal bone :
•Often fractures in head injury
•Dangerous : rupture of middle meningeal
artery  subarachnoid bleeding (dead if
massive)
•Vascular markings

5. Paranasal sinus :
Infection/inflammation  opacities
Abnormalities in Skull X-Ray :
•Congenital : microcephaly, macrocephaly,
cranio-synostosis
•Fracture : in head injury
•Bone disease : osteoporosis, osteoblastic
•Calcification :
Normal – in pineal gland, choroid plexus,
duramatter
Abnormal – AVM, brain tumour,
tuberculoma, advanced hemorrhagic
lesion
 Signs of increased Intra Cranial Pressure
(ICP)
Sellae destruction
Impressiones digitatae
Widening sutures (in children)
Increased vascular markings
Vertebra X-Ray
Projection :
AP, PA
Lateral, and
Obligue

Consist of : 7 cervical segments

12 thoracal segments
5 lumbal segments
5 sacrals segments
Vertebral X-Ray
Assess :
Shape –
Lordosis (normal in cervical and lumbal)
Scoliosis : HNP
Kyphosis : Tuberculous spondylitis
Vertebral body –
Destructive lesion in metastatic tumour,
inflammation
Compressive lesion in trauma
Intervertebral space –
disc protrusion in HNP
Vertebra X-Ray
Pedicles –
Attach to vertebra body : eroded and
destroyed by tumour
Articular process : luxation
Intervertebral foramina : widened in
neurinoma
Spinal process
Laminae : erosion  narrowed intervertebral
space
Spinal canal : stenosis if narrowed
Disorder of vertebral collumn
Congenital anomaly
Fracture/Dislocation
Inflammation
Tumour, etc
Myelography
Definition :
Introducing the contrast media into
subarachnoid space in order to
investigate CSF pathway

Procedure :
Point of insertion via
lumbal puncture in ascending
myelography
cisternal puncture in descending
myelography
Take out CSF in same as contrast agent
volume (about 10-20 mL)
Inject the contrast agent slowly
Take X-ray photo in various projections
needed (AP, Lateral, Obligue)
NEURORADIOLOGY -
SPINE
 HERNIATION NUCLEUS
PULPOSUS
Protrusion of disc material > 3 mm
beyond margins of adjecent vertebral
endplates involving < 50% of disc
circumference.
 CAUSE

• Ruptur of annulus fibrosus with

disc material confined within
posterior longitudinal ligament.
PROTRUSION EXTRUSION,
tooth-paste
sign
 Posterior disc herniation
• ASNR definition:
- Disc bulge : > 50% of circumference
- Disc protrusion: < 50%, wider than tall
- Disc extrusion: < 50%, taller than wide
 IMAGING MODALITIES
1. Plain film : not possible.
Bone density, narrowing disc space,
spurring, osteophyte.
2. Myelography: invasive.
3. CT/Myelo CT: visualisation nerve roots in the
thecal sac, time-consuming.
4. MRI: modality of choice.
Sagittal T1w and T2w.
Axial T1w and FSE T2w
PLAIN FILM
 MYELOGRAPHY
• Sharply indentation
• Asymetric of posterior disc margin
• Narrowing intervertebral disc space
• Deviation of nerve root
• Amputated/truncated nerve root
Multiple herniated disc.
Woman, 69 yrs: LBP & spinal
claudication.

Myelo CT:
-Spinal stenosis L4-L5 & L5-S1.
-Disc protrusion (L2-L3)
-Hyperthrophy ligamentum
flava,
-Facet joint arthritis.
 cT/Myelo ct
Width of spinal canal, lateral recess and
intervertebral foramina.
Spondylsis, osteophyte, spur & bone density
Protrusion/herniation density 60-80 HU.
Convex bulging at posterior, laletral border.
Compression of nerve roots
Sequestrum
CERVICAL REGION
 Thoracal region

Myelo CT: Th6-Th7 medial disc Th11-Th12 intraforaminal

protrusion. disc protrusion
L4-L5 intraforaminal L4-L5 medial disc protrusion
disc protrusion
L4-L5 extraforaminal L4-L5 infraforaminal right disc
right disc herniation. herniation.
 MRI
• Endplate marrow changes:
- T1w hipointensity, T2w hyperintensity:
vascular granulation tissue, enhance.
- T1w hyperintensity, T2w isointense or
hyper: fatty marrow replacement.
- T1w hypo, T2w hypo: sclerosis
• Degenerated discs:
- T2w hypointense.
Osteophyte and facet hyperthrophy
 Hyperthrophy of ligmentum flavum
Man, 80 yrs.
A. Sagittal T2w FSE. Concentric disc protrusion,
spondylarthrosis, hypertrhrophy lig. flava.
B. Cauda equina fibers above stenosis have a typical
elongated and wavy appearance.
a b c

Woman, 59 yrs. 2 mos after intevertebral disc surgery.

a. Sagittal T2w TSE. Recurrant disk prolapse.L3-L4.
b. After contrast, peripheral enhancement of prolapse disc.
c. Axial T2w TSE. Herniated disc on the right mediolateral
side.
 Sagittal T1wi:

-Endplate changes L5-S1

Disc psudobulge
 T2Wi.

L5-S1 Large extrusion with free fragment, inferior migration.

L4-L5 Small protrusion..
Sagittal T2wi: Extrusion
intervertebral disc.
Sagittal T2wi: Limbus CT : Limbus fracture,
herniation, focal contour posterosuperior margin.
defect.
Spondylitis TB
 II. Spontaneous Intracranial
Hematoma;

Intraparenchymal hematoma

DDX : Causes of intraparenchymal

hematoma
1. Aneurysm rupture
2. Arteriovenous malformation
rupture
3. Hypertension
4. Tumor
 PENDAHULUAN

PREVALENSI (USA) : 5,3 JUTA ORANG

/TAHUN DENGAN ANGKA KECACATAN
80.000 – 90.000 0RANG
DIATASI TIDAK DIATASI

KOMPLIKASI PRIMER : PERDARAHAN

INTRAKRANIAL

MELIPUTI
SEMB INTRASEREBRI DAN . . .
UH CACAT KEMATIAN
Extra-axial collections
 EPIDURAL HEMATOMA
FRAKTUR TULANG

•
TENGKORAK
GEJALA KLINIS :
EPIDEMIOLOGI
PENURUNAN KESADARAN
• ETIOLOGIPENGLIHATAN ROBEKAN
BINGUNG
A. MENINGEA MEDIA
KABUR
• PATOFISIOLOGI SUSAH BICARA
NYERI KEPALA YANG HEBAT
PENEKANAN LOBUS HEMATOMA
PENINGKATAN
KELUAR CAIRAN DARI HIDUNG ATAU TELINGA TIK
•
TEMPORALIS
KLINIS
LUKA YANG DALAM ATAU GORESAN PADA KULIT KEPALA
MUAL
• HERNIASI LOBUS
BAGIAN MEDIAL
PUCAT
IMAGING PUPIL ANISOKHOR
NEUROLOGIC
SIGNS
DECEREBRATE
• KEKAKUAN
• GANG. VITAL SIGNS
• GANG. PERNAFASAN

• PENATALAKSANAAN
EPIDURAL HEMATOMA
• Pada umumnya single
• Berbentuk bikonveks
• Densitas darah
hiperdens
• Berbatas tegas
• Midline terdorong ke
sisi kontralateral
• Paling sering di daerah
temporoparietal
 EPIDURAL HEMATOMA
PENATALAKSANAAN
• DEKOMPRESI
• KRANIOTOMI
• ELEVASI KEPALA 30˚
PROGNOSIS :
• MEDIKAMENTOSA :
DEXAMETASON :LOKASI dosis awal 10 mg, 4mg/6 jam
MANNITOL 20% : 1-3 mg/kgBB/hari
PROFILAKSIS LUAS / BESAR
KESADARAN
BARBITURAT : dosisSAAT MASUK
awal 10 OKdalam 30
mg/kgBB
menit, 5 mg/kgBB/3 jam serta drip 1 mg/kgBB/jam
• OPERATIF
 SUBDURALTRAUMA
HEMATOMA
SUBDURAL TULANG
TERJADI DALAM LAPISAN DURAMETER LIKUEFAKSI
•
HIGROMA TENGKORA
EPIDEMIOLOGI
AKUT :
DURAMETER
SERING TERJADI PADA CEDERA
CEDERA K KEPALA BERAT
KEPALA
SDH AKUT
MAUPUN
TERBENTUK
TERPISAH DARI AKSELERASI
• ETIOLOGI
ARACHNOID
ANTIKOAGULAN
RINGAN
SEREBRI
PERDARAHAN INTRAKRANIAL NON-TARUMATIK
MEMBRAN
DURA –
CSFMENINGKAT
MENGISI PADAPOST TERHADAP
LANSIA
PEMBEDAHAN
YANG MENGGUNAKAN ANTI
• PATOFISIOLOGI
VENA
CELAH
PROLIFERASI
PERMUKAAN
STRUKTUR
HIPOTENSI
KOAGULAN DURA HEMATOMA
INTRAKRANIAL
ROBEKAN
ARTERI
TERBENTUK
(W.1)
KORTIKAL
• SEL
KRONIS DURA
KLINIS
KORTEKS
MEMBENTUK
:
SINUS
AKUT %RUPTUR
– : 5 – 25PEMBULUH
CEDERA
PASIEN DENGAN CKB
PEMBULUH
DARAHKEPALA
MEMBRAN
SEKITAR
OTAK
FISSUE –
KRONIS : 1 – 5,3 KASUSSDH
/ 100.000
AKUT ORANG PER TAHUN
• MEMBRAN
IMAGING
DURALIS
BARU
DARAH
HEMATOMA
IDIOPATIK
HEMATOMA
HEMATOMA
SYLVIAN
(W.3)
LAKI-LAKI : WANITA = 3 : 1
SUBDURAL
SUBDURAL
• PENATALAKSANAAN AKUT
KRONIS
 SUBDURAL HEMATOMA
KRONIS : AKUT :
• GEJALA KLINIS
 TERLETAK DI PERIFER
:  TERLETAK DI PERIFER

• PUSING
 HIPODENS
 HIPERDENS
 BATAS DALAM YANG
• MUAL
 BATAS DALAM YANG
CEKUNG CEKUNG
• PERUBAHAN KEPRIBADIAN
• SULIT BICARA
• GEJALA NEUROLOGIS PASCA
TERJADINYA CEDERA KEPALA
• HEMIPARESE IPSILATERAL
 SUBDURAL HEMATOMA
• PENATALAKSANAAN :
 SESUAI DENGAN GEJALA KLINIS
 DEFINITIF  PEMBEDAHAN

• PROGNOSIS :
 PENATALAKSANAAN
 BESARNYA KERUSAKAN OTAK
 ANGKA KEMATIAN : 60 % (DENGAN
KERUSAKAN OTAK)
 TANPA KERUSAKAN OTAK : 20 %
 SUBARACHNOID
HEMATOMA
• EPIDEMIOLOGI
• ETIOLOGI
• PATOFISIOLOGI
• KLINIS
• IMAGING
• PENATALAKSANAAN
 SUBARACHNOID
HEMATOMA
TRAUMA
ETIOLOGI : KEPALA PERDARAH
EPIDEMIOLOGI
KONTUSIO AN
• PERDARAHAN
TRAUMA
SEREBRI KEPALA DI RUANG SUBARACHNOID
AKSELER INTRAVENT
GEJALA KLINIS :
• NON-TRAUMATIK ASI
ANEURISMA INTRAKRANIAL
MENINGKAT
ANGULAR
RIKEL
PADA
 USIA
AVM 25 – 64 TAHUN
 DISEKSI SULIT DITENTUKAN
KERUSAKAN
ARTERI
•UMUMNYA PEMBULUH
80% KARENA
: ANEURISMA
MENINGEAL
SUBARACHNOI SIGN + (timbul dalam
KERUSAKAN
 IATROGENIC
DARAH
ARTERI–VENA
D 3HEMATOMA
12 jam)AKSONAL
 FISTULA
SUPERFICIA
 MENINGITIS
ROBEKAN
L PEMBULUH
 NEOPLASMADARAH KECIL DI
RUANG
SUBARACHNOID
SUBARACHNOID
HEMATOMA
 SUBARACHNOID
HEMATOMA
PENATALAKSANAAN :
PROGNOSIS :
• KATETERASI PADA TEMPAT OKLUSI :
GUIGLIELMI DETACHABLE COIL
KLASIFIKASI KEPARAHAN TRAUMA
(GDC)
• ANGIOPLASTI
VOLUME PERDARAHAN
INTRAKRANIAL
• INFUS INTRA DISTRIBUSI SAH PAPAVERIN
ARTERIAL
 Three Stroke Types
Ischemic Intracerebral Subarachnoid
Stroke Hemorrhage Hemorrhage

Clot occluding Bleeding Bleeding around

artery into brain brain
85% 10% 5%
www.acponline.org/about_acp/cha
pters/ok/gordon.ppt
Causes of ICH

http://spinwarp.ucsd.edu/neurowe
b/Text/non-trauma-ER.htm
Cerebral Hemorrhage

JPG
Cerebellar Hemorrhage
 Subarachnoid Hemorrhage
• “Worst headache of my life”
• AMS
• Photophobia
• Nuchal rigidity
• Seizures
• Nausea and vomiting
Subarachnoid Hemorrhage