Basic Neuroimaging (CT

and MRI)
Dr Sean E Mc Sweeney
2007/2008
 Indications for CT scan:
1) Significant Head Injury
2) Acute Stroke
3) Acute Headache (to look for SAH)

Indications for MRI:

4) Progressive focal neurological deficit
5) Epilepsy
6) Infections
7) Degenerative diseases
Multislice Helical CT scanner
 Basic CT Physics
CT overcomes superimposition of structures

Measures and records small differences in tissue density

Highly collimated x ray beam passes through the head –

with different tissues attenuating this beam differently

Detectors on the other side gather information about

attenuation characteristics and with mathematical
algorithms compute an image
 Normal CT Brain Scan
CT Scan above the level of the lateral ventricles

Frontal
Lobe

Centrum
Semiovale
Falx
Cerebri Parietal
Lobe

Without Contrast With Contrast

Normal CT Brain Scan
CT Scan at the level of the lateral ventricles

Frontal
Lobe

Frontal Horn of Head of Caudate

Lateral Ventricle Nucleus
Thalamus
Posterior Horn of
Lateral Ventricle

Occipital Lobe
 Normal CT Brain Scan
CT Scan at the level of the 3rd Ventricle

Sylvian Head of Caudate Nuc

Vessels
Ant + Post Limbs of the Frontal Horn of
Lateral Ventricle
Internal Capsule
Lentiform
Nucleus
Tectum of Midbrain
Temporal Lobe

Confluence of Venous
Sinuses (Torcula)

Without Contrast With Contrast

 Normal CT Brain Scan
CT Scan at the level of the 4th Ventricle

ACA MCA
Temporal Lobe Basilar Artery
Pons
4th Ventricle

Without Contrast With Contrast

 Hounsfield Unit (CT Density)
Tissue Hounsfield Unit
Black
Air -1000

Fat -40 to -100

Fluid 0 to 20

Soft Tissue 20 to 100

White Matter 20 to 35
Grey Matter 30 to 40

Acute Hemorrhage 55 to 75
Bone 1000
White
 
 Example on CT

Grey Matter
White Matter

Grey Matter

Air (-1000)
Fluid CSF (0-20)

Bone (1000)
 Case Examples on CT
-80 HU 140 HU 70 HU

Lipoma (Fat) Calcification Acute hematoma

(in meningioma)
Brain Windows vs. Bone Windows

CT of fibrous dysplasia of skull with brain and

bone windows
Evolution of Hematoma on CT

Acute hematoma: 4 hrs

4 days

3 months after initial CT

Decreasing Density of Hematoma

• Acute : hyperdense (1 to 6 days)

• Subacute: isodense (6 to 12 days)

• Chronic : hypodense ( > 12 days)

 Classic Infarct on CT
ACA
MCA

PCA

• Wedge shaped area of low density in

right middle cerebral artery territory
Acute Extradural hematoma
Extradural Hematoma - evolution

Acute extradural Chronic epidural

hematoma hematoma
 Extradural Hematoma
• Extradural hematomas are located between the inner
table of the skull and the dura.
• They are typically biconvex in shape because their
outer border follows the inner table of the skull and their
inner border is limited by locations at which the dura is
firmly adherent to the skull.
• Epidural hematomas are usually caused by injury to an
artery, although 10% of epidural hematomas may be
venous in origin.
• The most common cause of an epidural hematoma is a
linear skull fracture that passes through an arterial
channel in the bone(middle meningeal artery).
• Epidural hematomas, especially those of arterial origin,
tend to enlarge rapidly
 Subarachnoid Haemorhage (SAH)

Acute Subarachnoid Haemorrhage in region of Circle of Willis (Yellow)

 Subarachnoid Haemorhage
• CT without contrast
– CT is the most sensitive imaging study in SAH .
– Findings may be negative in 10-15% of patients with
SAH.
– Maximum sensitivity is within 24 hours after the event;
sensitivity is 80% at 3 days, 50% at 1 week.
– Look for evidence of hydrocephalus (trapped temporal
horns and "Mickey Mouse" appearance of ventricular
system).
– Look for intraparenchymal clot, intraventricular
hematoma, and interhemispheric hematoma
 Hydrocephalus and SAH

• Haemorrhage can be seen in the ventricular spaces normally containing

CSF, (dark grey replaced by white) which are dilated (Hydrocephalus)
also the sylvian fissure are visable due to the presence of SAH.
 CT Cerebral Angiography
MCA ACA

PCA Carotid

• 3D CT Angiography of the Brain Allows Extremely Detailed and

Precise Visualization of the Cerebral Vessels and the Circle of Willis
that is Safe and Noninvasive
Ct Angiography

A Subarachnoid hemorrhage in the right sylvian

fissure (arrow), B, 3D volume-rendered image
(lateral) shows inferiorly and posteriorly directed
saccular aneurysm at the origin of the right
posterior communicating artery (arrow).
C,Preoperative right internal carotid digital
subtraction angiogram shows corresponding
saccular aneurysm. D, Angiogram shows
successful clip placement in the posterior
communicating artery aneurysm.
CT Aorta
 Acute Subdural

Acute subdural (White) on chronic (Yellow)

and mass effect :midline shift (Red arrow)
 Acute Subdural
• Subdural hematomas are located between the dura and
the brain.
• Their outer edge is convex, while their inner border is
usually irregularly concave (cresenteric).
• Subdural hematomas cross the intracranial suture
lines; this is an important feature that aids in their
differentiation from epidural hematomas.
• Subdural hematomas are usually venous in origin,
although some subdural hematomas are caused by
arterial injuries.
• The classic cause of a posttraumatic subdural
hematoma is an injury to one of the bridging veins that
travel from the cerebral cortex to the dura.
 The MRI machine

1.5 Tesla magnet

 Magnetic resonance imaging

• Magnetic resonance imaging is based on imaging of

protons within the human body
• Images produced are based on a computer
calculation of how protons within different soft
tissues react to the application of a strong magnetic
field and radiofrequency pulse
 MRI Is Similar to an Orchestra

Different music can be produced by changing the parameters used

 MRI Sequences - NORMALS
T1
T2

FLAIR
T1 vs. T2 Appearances
 MRI Indications
• Neurology
- acute cerebral infarction
- brain tumour
- white matter disease
- spinal cord problems
- posterior fossa-better than CT
- paediatric-avoids radiation
- head trauma
 Acute Infarct: CT vs. MRI
MRI can show acute infarcts:
CT very useful to r/o bleed useful if thrombolytic therapy
being considered

DWI
Brain tumor-GBM
Multiple sclerosis
 Multiple sclerosis
• MRIs typically demonstrate more than 1 hyperintense
white matter lesion on T2.
• Lesions may be observed anywhere in the CNS white
matter (supratentorium, infratentorium, and spinal cord).
• Typical locations for MS lesions include the periventricular
white matter, brainstem, cerebellum, and spinal cord.
• Ovoid lesions perpendicular to the ventricles are common
in MS and occasionally are called Dawsons fingers.
• Perhaps the most specific lesions in MS are noted in the
corpus callosum at the interface with the septum
pellucidum
• Proton density (PD) MRI has an advantage over standard
T2 imaging because, on PD series, MS lesions remain
hyperintense while CSF signal is suppressed
HSV Encephalitis
 Spinal Cord Lesion on CT

Ewing’s sarcoma arising from the cervical spine

 Spinal Cord Lesion on MRI
T1 sagittal T1 sagittal C + T2 sagittal

Ewing’s sarcoma arising from the cervical spine with

cord compression
 Cord astrocytoma

T1 T1, with
T2
contrast
Acoustic Neuroma
 Blood Products

Acute hematoma best seen on CT

Subacute and chronic hematoma better

evaluated on MRI

Primary (hypertensive)
bleeds occur in the basal
ganglia; for bleeds at other
locations, hunt for a cause
Subacute Hematoma on MRI
Right paraasagittal T1WI Left paraasagittal T1WI
(normal side)

Axial FLAIR image Axial T2 image

Chronic Resolved Hematoma

Now shows “slit” like cavity with hemosiderin stain

 Advantages of MRI v CT
• No ionising radiation
• Multiplanar imaging capability
• Non-invasive vascular imaging
• Cardiac imaging
• Excellent contrast resolution-much better
than CT
• No streak artifacts from bone
• Safer contrast agent (Gadolinium)
• Molecular imaging
 Disadvantages of MRI v CT
• More expensive
• More motion sensitive
• Limited availability
• Contraindicated in certain patients
• Acute haemorrhage difficult to see (SAH)
 Contraindications for magnetic
resonance imaging

• Cranial metal i.e. head, brain, orbit

• Pacemaker
• History of metalwork, shrapnel
• Claustrophobic
Positron Emission Tomography
 What is Positron Emission
Tomography (PET)

• Positron emission tomography (PET scan) is a

diagnostic examination that involves the
acquisition of physiologic images based on the
detection of radiation from the emission of
positrons.
• Positrons are emitted from a radioactive
substance administered to the patient. The
subsequent images of the human body
developed with this technique are used to
evaluate a variety of diseases
 PET Scanning
• F-18 2 fluoro-2 deoxy-D-glucose (FDG) is
a glucose analog labeled with positron-
emitting fluorine-18.
• Most malignant tumors are
metabolically active and take up
increased FDG relative to normal tissue.
• FDG is highly sensitive in identification of
malignant tumors.
 PET-CT
• PET-CT is the fusion of functional and
anatomic information acquired almost
simultaneously.
• By combining the structural anatomic
information with functional data, we are
able to visualize form and function
PET-CT
Lung cancer with metastatic
mediastinal lymph nodes
Lung cancer with metastatic
Adrenal mass