Review to CNS radiology
including Special Senses
Bisher Al-Halabi
Collected from different resources
and handouts
Outline
• Theory and introduction
• Spine and content
• Brain stem radiology
• Cortex and skull - Blood supply
• SOL DDx and examples
• SS
• Questions…
1) Theory and introduction
• Need to know what to use, when
• Need to know advantage over disadvantage
• Need to know what appears how
• Need to know conditions
• I will present FEW cases only
• Theory and understanding more important
1) Plain X-ray
• Superficial clear bones
• Lowest radiation (compared to CT)
• Has limited function except for clear
superficial skull fractures
• Used in spinal skeleton injury
• Multiple would construct a CT
2) CT
• CT is ideal to demonstrate the fractures and deep
bones/ small bones that will not appear on plain
x-ray
• Constructed from different angular x-rays
• Used to see tissue relation to bone (anatomy )
• Used in SAH, ICH, etc
• Used over MRI as faster to appoint
• In SC fracture and relation of fragments to the
cord.
• High amount of radiation X pregnant
When??
- Brain infarction, hemorrhage (intracranial,
subdural,extradural)
- SAH, brain trauma, tumor
- Spine fracture (stable vs unstable)
- Lumbar disc, bone tumor
- Contrast can be used to check on cervical &
dorsal disc as well as spinal canal pathology (CT
Myelogram)
1-First About CT language
-Increased whiteness on a CT scan is referred to as -hyperdense or high
attenuation.
Causes of hyperdensities include:
Calcification
Acute hemorrhage
Ossification
Contrast
2-Increased darkness on a CT scan is referred to as hypodense or low
attenuation.
Causes of hypodensities include:
Air
Fat
Note that air appears darker than fat on a CT scan.
2--CT Without Contrast
When to Order
This is usually the first test performed in an emergency setting.
It is excellent at identifying blood.
--Advantages
If patient is stable, there are relatively no contraindications for
ordering this test. It is a fast exam that can be completed in
seconds.
-Disadvantages
Due to bony artifact, it is difficult to visualize abnormalities in the
posterior fossa and brain stem.
3-CT with Contrast
If no abnormality is seen without a contrast, then a scan with contrast could
be ordered to see if there is identifi able pathology. Contrast will help
identify
tumor, abscess, arteriovenous (AV) malformation, and aneurysm.
-Advantages
If a lesion enhances with contrast, then the blood-brain barrier is
compromised.
This can be seen in tumors, abscesses, and arteriovenous malformation.
-Disadvantages
Contrast will obscure an acute bleed. Thus, in an emergency setting, it is
important
to obtain a CT without contrast fi rst
Contrast
• Anaphylaxis
• Renal faluire
3)MRI
• Resonance built on magnetic bases
Multiplanar Imaging , Various Sequences,
No Radiation.
• T1-
• white matter to white,
• gray matter to gray,
• cerebrospinal fluid (CSF) dark.
• The contrast of white matter, gray matter and
cerebrospinal fluid is reversed
using T2 or T*2 imaging,
Indication
• Investigation of choice of almost all
neuropathology,
• great details in brain & spine.
• Brain tumors, MS
• Congenital, inflammatory
• pathology, cranial nerves
• MRA for Vascular abnormality.
• Differentiate between extradural, intradural,
• extramedullary and intramedullary pathology.
•T1 for highly
detailed anatomy
•T2 for abnormal
tissue
Sagital
2) Spine and content
• We will do SOL later
Tuberculous spondylodiscitis at the level L2/L3
T1 T2 Contrast
3) BS
• Check for cavernous sinus disease
• Myelination disorders
• Tumors
4) Stroke & BS
• Just a reminder
• The circle of Willis comprises the following arteries:
• Anterior cerebral artery (left and right)
• Anterior communicating artery
• Internal carotid artery (left and right)
• Posterior cerebral artery (left and right)
• Posterior communicating artery (left and right)
• The basilar artery and middle cerebral arteries, though
they supply the brain, are not considered part of the
circle.
Some theory again
The modality of choice is computed tomography(CT scan) of the
brain. This has a high sensitivity and will correctly identify over
95% of cases—especially on the first day after the onset of
bleeding.Magnetic resonance imaging (MRI) may be more
sensitive than CT after several days
Large Arteries:- Within the known territory of a major vessel,
middle, posterior, anterior and may include small arteries.
• Small Arteries:- ( Lacunar infarcts) Basal ganglia and
internal capsule, Thalamus, Pons, Deep white matter
CT Findings
• Area of decreased density involving the white and
gray matters (vs tumor)
• As early as 6 hours but usually after 24 hrs
• Mass effect that decreases with time. Effacement of
sulci.
• Brain edema may cause Brain herniation.
• The density of the lesion gets lower over 4 weeks
until similar to CSF with volume loss.
MRI
• Low on T1 and high signal on T2
• Less sensitive in detecting hemorrhage in infarction
• Typical parenchymal enhancement with contrast after
a week
--T1 images show fat as a white or bright signal, whereas
water (or cerebrospinal fluid [CSF]) is dark.
--On a T2 image, fat is dark, and blood, edema, and CSF
appear white
Distribution of the cerebral arteries
Posterior cerebral artery
Anterior cerebral artery Middle cerebral artery Anterior Cerebral artery
Posterior cerebral artery
Superolateral surface of the
Medial surface of the
cerebral hemisphere
cerebral hemisphere
Deep territory of the middle
cerebral artery
Superficial anterior (superior)
territory of the middle cerebral artery.
Superficial posterior (inferior) territory of
the middle cerebral artery
Hemorrhagic Infarcts
• Due to re perfusion
• Due to major embolism and in patients on anti coagulants
• Absence of blood on initial imaging
• In the center or at the margin
• Contraindication to anticoagulants treatment
• CT- space occupying high density area
• MRI – High signal on T1, Low on T2
CT BRAIN
A-- focally decreased density (darker than normal) due to stroke, edema, tumor,
surgery, or radiation
B-- increased focal density (whiter than normal) on a noncontrasted scan in ventricles
(hemorrhage) in parenchyma (hemorrhage, calcium, or metal) in dural, subdural,
or subarachnoid spaces (hemorrhage)
C- increased focal density on contrasted scan , tumor , stroke , abscess or cerebritis
aneurysm or arteriovenous malformation (AVM)
D- asymmetrical gyral pattern , mass or edema (causing effacement of sulci)
atrophy (seen as very prominent sulci)
E- midline shift
F- ventricular size and position (look at all ventricles)
G- sella for masses or erosion
H- sinuses for fluid or masses
I- soft tissue swelling over skull
J- bone windows for possible fracture
5) SOL
• Appearance depend on content
• Over all… tumors etc.. High on T2 low on T1
Cervical Ganglioglioma
T1 T1+C T2
T1+C Intra-operative
Lesions of The Spinal Canal.
1.Extradura 2.Intradural 3.Intradural
Extra-medullary Extra-medullary Intra-medullary
Disc
- herniation - Meningioma - Glioma
- infection (TB) - Epindymoma
Bone tumor
- Epidural - Drop metastasis
haemorrhage
- Epidural abscess
- Schwannoma
5) SOL of brain
Extra-Axial Intra-Axial
• Extra-Dural Haemmorage
•
• Cerebral Haematoma
Arachnoid cyst
• Intradural Haemmorage • Tumor (Glioma,
• Intradural Abscess
Metastasis,
• Meningioma
Medulloblastoma,
lymphoma)
• Schwanoma
• Dermoid/ epidermoid leasions
• Abscess
• Tuberculoma, sarcoid.
Acute Intra-dural Hematoma
High density, crescent
shaped hematoma
(arrowheads)
overlying the right
cerebral hemisphere.
Note the shift of the
normally midline
septum pellucidum due
to the mass effect
arrow.
Chronic Intra-dural Haematoma
Crescent shaped
chronic subdural
hematoma
(arrowheads). Notice
the low attenuation
due to reabsorbtion of
the hemorrhage over
time
Extra-dural Haematoma
Biconvex
extradural
hematoma
(arrowheads),
deep to the
parietal skull
fracture (arrow).
Intracerebral Haemorrhage
Ring – enhancing contrast on T1
-DDX
• malignant tumors
• high-grade glioma
• glioblastoma multiforme
• Metastasis (lung or breast)
• Nonneoplastic
• intracerebral abscesses (toxoplasmosis+fungal)
• demyelinating and reactive/resorptive lesions (acute
inflammatory demyelination,
• resolving hematoma or infarction, radiation necrosis)
• parasitic lesions (cysticercosis cyst, pork tapeworm).
6) SS – ear IMAGING - MODALITIES
• Plain X-ray has limited use due to thickness of the
Petrous bones
• Computerized Tomography – CT
– Imaging modality of choice - narrow CT slices (1.0
-1.5mm) for the demonstration detailed bony
anatomy
– Axial and Coronal series
• MRI is best for demonstration of soft tissue and
nerves
Acoustic neuroma
Phase 2 Integumentary system
2009
ENT
6) SS- eye
Classification of orbital lesions
Ocular lesion or non-ocular
i.e. is it involving the globe or involving the
structures outside the globe.
Non -ocular lesion,
• Intraconal space, i.e. within the space bounded by
the cone formed by the extraocular muscles,
•Conal -In the muscles
•Extraconal – Outside the muscles
Ocular lesions
• Specific pathologies :
• Rupture
• Hemorrhage
– Vitreous
– Retinal
• Infection:
• Retinal detachment
Non-ocular - Intra-conal
The intraconal space is marked by arrows and is located within the muscle cone
It contains the optic nerve, vessels and cranial nerves III, IV
Nov. 2009 ORBITS 48
Extraconal space
• The extraconal space is the area
outside the muscle cone.
• Extraconal space pathology:
• Abscess due to sinusitis
• Schwannoma of the V1 and V2
branches of the trigeminal nerve
• Bone lesions:
– Fibrous dysplasia of the
sphenoid wing
– Metastases
– Multiple myeloma
•
Nov. 2009 ORBITS 49
Orbital trauma Indications
• CT – Is the modality of choice - Gives very good
bony detail
• Plain x-ray will appear normal!!!
• Evidence of fracture on clinical examination
• Limitation of eye movement
• Decreased visual acuity in setting of trauma
• Severe pain
• Difficult examination due to soft tissue swelling
Nov. 2009 ORBITS 50
ORBITAL TUMORS
• Usually presents with exolphalmos or
proptosis
• Eye displacement due to tumor location CT
shows tumor and associated bone destruction
if present
• MRI - gives excellent soft tissue
demonstration
Nov. 2009 ORBITS 51
• Any questions???
