Intracranial radiology general presentation

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tutorial for medical graduate

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Intracranial radiology general presentation

  1. 1. Basics for medical students By_ Dr. Rekha Khare M.D. radiology
  2. 2. Intracranial Lesion How to image?
  3. 3. Imaging modality <ul><li>Simple radiography </li></ul><ul><li>-cheap preliminary screening </li></ul><ul><li>procedure </li></ul><ul><li>-accuracy & specificity is low </li></ul>
  4. 4. contd. <ul><li>Computerized tomography- basic choice </li></ul><ul><li>MRI – tissue specification is better </li></ul><ul><li>Ultrasound scan- choice in neonate & infant </li></ul>
  5. 5. contd. <ul><li>Angiography- mainly for interventional radiology </li></ul>
  6. 6. contd. <ul><li>Radionuclide scan- </li></ul><ul><li>- basic technique is superseded by CT & MRI </li></ul><ul><li>-Technique for mapping regional cerebral blood flow has important clinical application as in CVA, Dementia, Alzhiemers etc </li></ul>
  7. 7. contd. <ul><li>Positron emission tomography (PET) </li></ul><ul><li>expensive & available in very advance centre ( cyclotron) </li></ul><ul><li>PET tracer like carbon, nitrogen, oxygen </li></ul><ul><li>- specific & showing difference in focal brain metabolism </li></ul><ul><li>- Major use in oncology </li></ul>
  8. 8. contd. <ul><li>SPECT </li></ul><ul><li>- Imaging of dopamine transport system in movement disorder (like Parkinsonism) by injecting specific tracer agent working at neuromuscular junction </li></ul>
  9. 9. When to ask brain CT scan <ul><li>Head injury </li></ul><ul><li>Cerebro-vascular accident </li></ul><ul><li>Unconscious </li></ul><ul><li>Epilepsy </li></ul><ul><li>Pyrexia of unknown origin </li></ul><ul><li>Suspecting intracranial mass lesion </li></ul>
  10. 10. How to read CT scan brain <ul><li>Identification </li></ul><ul><li>Technical details </li></ul><ul><li>Examine the image </li></ul><ul><li>Localize the lesion </li></ul><ul><li>Analyse the lesion </li></ul><ul><li>Possible diagnosis </li></ul><ul><li>D/D if needed </li></ul>
  11. 11. Identification <ul><li>Name, age, sex, of patient </li></ul><ul><li>Date of exam. </li></ul><ul><li>(printed on scan) </li></ul>
  12. 12. Technical detail <ul><li>Scout film/ scanogram </li></ul><ul><li>Plane _ axial, coronal, sagittal </li></ul><ul><li>Number of slices </li></ul><ul><li>Thickness of slice( 1-10mm) </li></ul><ul><li>Window </li></ul><ul><li>( printed on CT scan ) </li></ul>
  13. 13. Window means <ul><li>Window_ wl (window level) </li></ul><ul><li>ww (window width) </li></ul><ul><li>Brain window 35-40/ 70-85 </li></ul><ul><li>Bony window 350/ 2500-3000 </li></ul><ul><li>Sometimes subdural window (70/300) </li></ul><ul><li>(printed on CT scan) </li></ul>
  14. 14. Basic idea of CT value <ul><li>0-- water </li></ul><ul><li>20-32-- white matter </li></ul><ul><li>30-40-- grey matter </li></ul><ul><li>56-70-- blood </li></ul><ul><li>80-1000-- calcification to bone </li></ul><ul><li>+100-- fat </li></ul><ul><li>-1000-- air </li></ul>
  15. 15. Technical detail <ul><li>Plain </li></ul><ul><li>Contrast- viable & vascular tissue take contrast </li></ul><ul><li>( printed on CT scan) </li></ul>
  16. 16. Examine the image_ a systematic approach <ul><li>Midline_ shift </li></ul><ul><li>Ventricle, cistern, sulci_ enlarged, compressed, displaced </li></ul><ul><li>Brain tissue_ iso/hypo/hyper/hetero </li></ul><ul><li>_ mass effect </li></ul><ul><li>_ gyri enhanced </li></ul><ul><li>_ white matter </li></ul>
  17. 17. Contd. <ul><li>Bones/ vault( # /mass/erosion) </li></ul><ul><li>Scalp/ soft tissue </li></ul>
  18. 18. Localize the lesion <ul><li>Commonly look for_ </li></ul><ul><li>-air sinus_ frontal/ethmoid/sphenoid </li></ul><ul><li>-ventricle_ LV ant./ temporal/ occipital horn </li></ul><ul><li>_ 3 rd and aqueduct </li></ul><ul><li>_4 th and cisterna magna </li></ul>
  19. 19. Contd. <ul><li>cistern_ cerebellopontine </li></ul><ul><li>_ suprasellar </li></ul><ul><li>_ quadrigeminal </li></ul><ul><li>_ interpeduncular </li></ul><ul><li>sulci and gyri </li></ul><ul><li>sylvian fissure </li></ul>
  20. 20. Contd. <ul><li>Cerebral lobes_ frontal/temporal/occipital/ </li></ul><ul><li>parietal </li></ul><ul><li>Mid brain </li></ul><ul><li>Brain stem </li></ul><ul><li>cerebellum </li></ul>
  21. 21. Contd. <ul><li>Basal ganglion </li></ul><ul><li>-caudate nucleus (head indenting ant. horn) </li></ul><ul><li>-lentiform nucleus </li></ul><ul><li>-external capsule (in between </li></ul><ul><li>insula and lentiform nucleus) </li></ul><ul><li>-internal capsule ( in between </li></ul><ul><li>caudate and lentiform nucleus) </li></ul>
  22. 22. Contd. <ul><li>thalamus_ on either side of 3 rd ventricle </li></ul><ul><li>pineal body </li></ul><ul><li>choroid plexus </li></ul><ul><li>hypothalmus </li></ul><ul><li>basilar artery </li></ul><ul><li>great vein of galen ( post. to pineal) </li></ul>
  23. 23. Contd. <ul><li>corpus callosum </li></ul><ul><li>-genu ( ant. to ant. horn of LV) </li></ul><ul><li>-splenium (post. to occ. horn of LV) </li></ul><ul><li>septum pellucidum </li></ul><ul><li>tentorium( dura seperating cerebellum from cerebrum) </li></ul>
  24. 24. Contd. <ul><li>venous sinus </li></ul><ul><li>-sigmoid ( along petrous/ temporal bone) </li></ul><ul><li>-transverse( between sigmoid and sup. sagittal sinus) </li></ul><ul><li>-superior sagittal sinus( midline, falx meets inner skull table) </li></ul>
  25. 25. Contd. <ul><li>white matter/ corona radiata </li></ul><ul><li>foramen magnum </li></ul><ul><li>-spinal cord </li></ul><ul><li>-vertebral artery </li></ul>
  26. 26. Analyse the lesion <ul><li>Intra/ extra axial </li></ul><ul><li>Supra/ infra tentorial </li></ul><ul><li>Single/ multiple/diffuse </li></ul><ul><li>White/ grey matter/ both </li></ul><ul><li>Enhancement </li></ul><ul><li>-non enhanced_ avascular </li></ul><ul><li>-hyper enhanced_ vascular </li></ul><ul><li>-heterogenous enhanced_ mass </li></ul>
  27. 27. Possible pathology <ul><li>Mass </li></ul><ul><li>Infarction </li></ul><ul><li>Haemorrhage </li></ul><ul><li>Hypoxic </li></ul><ul><li>demyelinating/ degenerative </li></ul>
  28. 28. Possible etiology <ul><li>congenital/ developmental </li></ul><ul><li>traumatic </li></ul><ul><li>infection/inflammatory </li></ul><ul><li>mass/ neoplasm </li></ul><ul><li>parasitic </li></ul><ul><li>vascular </li></ul><ul><li>degenerative </li></ul><ul><li>metabolic/ toxic </li></ul><ul><li>iatrogenic/ post procedural </li></ul>
  29. 29. Onset of lesion <ul><li>acute </li></ul><ul><li>sub acute </li></ul><ul><li>chronic </li></ul><ul><li>recurrent </li></ul><ul><li>residual </li></ul><ul><li>old healed </li></ul>
  30. 30. Possible diagnosis <ul><li>In correlation with_ </li></ul><ul><li>age, sex </li></ul><ul><li>clinical signs and symptoms </li></ul><ul><li>other imaging results </li></ul><ul><li>any lab tests </li></ul>
  31. 31. Differential diagnosis_ common <ul><li>Intra axial_ </li></ul><ul><li>m_ mass/ metastasis </li></ul><ul><li>a_ abscess/ angioma </li></ul><ul><li>g_ glioma/ gliosis </li></ul><ul><li>i_ infarction/ infection/ inflamation </li></ul><ul><li>c_ contusion/ congenital </li></ul><ul><li>dr_ demyelination/degenerative </li></ul>
  32. 32. Contd. <ul><li>Extra axial_ meningioma </li></ul><ul><li>pit. Adenoma </li></ul><ul><li>craniopharyngioma </li></ul><ul><li>chordoma </li></ul><ul><li>schwanoma </li></ul><ul><li>lipoma </li></ul><ul><li>dermoid/ epidermoid </li></ul>
  33. 33. Sample report <ul><li>This is CT scan of head done on </li></ul><ul><li>----- for ----- age --- </li></ul><ul><li>Axial cuts in----mm slices from foramen magnum to vertex </li></ul><ul><li>Plain and enhanced views with brain and bone window are included </li></ul><ul><li>Radiological findings are----- </li></ul><ul><li>In clinical context of ----- duration these findings suggest -------- </li></ul><ul><li>Other D/D( if needed) could be---- </li></ul>
  34. 34. Few pictures Material collected while working as consultant radiologist in university teaching hospital Lusaka Zambia
  35. 35. Brain trauma <ul><li>depressed # with brain haematoma causing mass effect </li></ul>
  36. 36. Brain trauma <ul><li>Subdural haematoma </li></ul>
  37. 37. Mass at top of head <ul><li>Predominantly extracranial mass destruction of bones </li></ul>
  38. 38. Intracranial mass-plain <ul><li>Well outlined hyperdense </li></ul><ul><li>mass in frontal lobe </li></ul><ul><li>?Meningioma </li></ul>
  39. 39. Same case- contrast <ul><li>Huge hyperdense enhanced mass from falx with oedma in surrounding brain tissue ? meningioma </li></ul>
  40. 40. Brain mass <ul><li>Heterogenous enhanced cystic mass compressing 4 th ventricle causing hydrocephalus </li></ul>
  41. 41. Brain mass <ul><li>Heterogenous enhanced solid mass , compressing 4 th ventricle causing hydrocephalus </li></ul>
  42. 42. Brain mass <ul><li>Strongly enhanced mid line lesion within 4 th ventricle causing obstructive hydrocephalus ? ependymoma </li></ul>
  43. 43. Brain mass <ul><li>Hypodense nonenhanced mass in cerebellar region displacing 4 th ventricle </li></ul><ul><li>? Glioma </li></ul>
  44. 44. Brain mass <ul><li>Cystic mass with calcification compressing/ displacing 4 th ventricle with </li></ul><ul><li>hydrocephalus </li></ul><ul><li>? ependymoma </li></ul>
  45. 45. Brain mass <ul><li>Heterogenous cystic mass with mass effect </li></ul>
  46. 46. Brain mass <ul><li>Cystic mass lesion causing dilated LV ? colloidal cyst </li></ul>
  47. 47. Brain mass <ul><li>Calcified mass at level of 3 rd ventricle </li></ul>
  48. 48. Brain mass <ul><li>Strongly enhanced mass lesion at pitutary level ? Adenoma </li></ul>
  49. 49. Brain mass _ metastasis <ul><li>Extradural deposit </li></ul><ul><li>with bone destruction_ </li></ul><ul><li>Primary unknown </li></ul>
  50. 50. Brain mass _ metastasis <ul><li>Deposit with bone destruction </li></ul>
  51. 51. Brain mass _ plain <ul><li>Hyperdense mass with oedma, mass effect, falx calcification? </li></ul>
  52. 52. Same case _ contrast <ul><li>? Malignant Meningioma </li></ul>
  53. 53. CVA_ acute hemiplegia <ul><li>Intracerebral haematoma basal nuclei region with mass effect </li></ul>
  54. 54. CVA _ acute hemiplegia <ul><li>Acute infarct </li></ul>
  55. 55. Old case hemiplegia <ul><li>Hypodense lesion with no mass effect </li></ul><ul><li>Overfilled lateral ventricle ? Few days old infarction </li></ul>
  56. 56. CVA_ Acute hemiplegia <ul><li>Serpegenious strongly enhanced lesion with mass effect ?AVM </li></ul><ul><li>Angiography is next modality </li></ul><ul><li>to confirm </li></ul>
  57. 57. Unconscious <ul><li>Brain oedma_ </li></ul><ul><li>(White cerebellar sign) </li></ul>
  58. 58. Dementia <ul><li>Multiple hypodense lesion mainly peripheral </li></ul><ul><li>? Infarcts in old age </li></ul>
  59. 59. Neonatal brain <ul><li>Dilated ventricle compressing brain tissue, few calcification </li></ul><ul><li>HIV+ve mother </li></ul><ul><li>? CMV </li></ul>
  60. 60. Neonatal brain <ul><li>Dying/ hypoxic brain </li></ul>
  61. 61. Brain infection _ plain <ul><li>Acute hydrocephalus </li></ul>
  62. 62. Same case _ contrast <ul><li>Acute hydrocephalus with meningeal enhancement </li></ul>
  63. 63. Brain infection _ plain <ul><li>Chronic SDE with mass/ pressure effect </li></ul>
  64. 64. Same case _ contrast <ul><li>Enhanced membrane _ subdural empyema </li></ul>
  65. 65. Infection_ plain <ul><li>Vague hypodensity with mass effect </li></ul>
  66. 66. Same case _ contrast <ul><li>Multiple ring enhanced lesion </li></ul><ul><li>? abscess </li></ul>
  67. 67. Fever_ plain <ul><li>Thin ring lesion with massive oedma & mass effect </li></ul>
  68. 68. Same case_ contrast <ul><li>Multiple ring enhanced lesion with midline shift & mass effect- ? abscesses </li></ul>
  69. 69. HIV+ve case_ plain <ul><li>Multifocal hypodense lesion with no mass effect </li></ul>
  70. 70. Same case- contrast <ul><li>Enhanced nodular lesion? opportunistic infection </li></ul>
  71. 71. HIV+ve case <ul><li>Multinodular enhanced lesion with massive oedma </li></ul>
  72. 72. HIV+ve case <ul><li>Multinodular hyperdense lesion with massive oedma </li></ul>
  73. 73. HIV+ve case <ul><li>Basal ganlion calcification </li></ul>
  74. 74. Epilepsy/ fits <ul><li>calcifiation in periventricular region ? Tuberous sclerosis </li></ul>
  75. 75. Epilepsy/fits <ul><li>Cysticercosis </li></ul>
  76. 76. Acute Headache <ul><li>Dilated ventricles with meningeal enhancement ? meningitis </li></ul>
  77. 77. Post procedural <ul><li>Shunt seen </li></ul><ul><li>Bilateral subdural effusion </li></ul><ul><li>Common complication </li></ul><ul><li>Rabbit ear appearance </li></ul>
  78. 78. Unsteady gait <ul><li>Cerebellar atrophy </li></ul>

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