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Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
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Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
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Diagnosticneuroradiology 091217195506-phpapp01
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Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
Diagnosticneuroradiology 091217195506-phpapp01
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  • 1. Diagnostic Radiology of Central Nervous System Raphael B. Jiang, Section of Diagnostic Radiology Sun Yat-Sen University First Affiliated Hospital
  • 2. Outline Normal Imaging Anatomy of Brain Basic Features of Brain Lesions Brain Tumor Cerebrovascular Disease Traumatic Brain Injury
  • 3. Normal Imaging Anatomy of Brain Meninges Dura mater Falx cerebri Tentorium cerebelli Venous sinuses Arachnoid mater subdural space a potential space btw dura and arachnoid subarachnoid space interval btw arachnoid and pia Pia mater
  • 4. Normal Imaging Anatomy of Brain MeningesTentorium cerebelli Falx cerebri
  • 5. Normal Imaging Anatomy of Brain Meninges S. sagittal sinusArachnoid granulationDura materArachnoid Falx cerebriSubarachnoid spacePia mater
  • 6. Normal Imaging Anatomy of Brain MeningesFalx and TentoriumIso-/-mildly hyperdense compared with cortex on CTHyperdense when calcifiedMarkedly enhanced after iodine contrastHypointense in T1WI and T2WIHomogeneity in signal intensityMarkedly enhanced after Gadolinium
  • 7. Normal Imaging Anatomy of Brain Cerebral Hemisphere The layer of gray matter covers entire surface of cerebral hem. Its deep layer is white matter and nucleus Gray matter is slightly hyperattenuating than white matter White matter slightly hyperintense than gray matter on T1WI Gray matter hyperintense than white matter on T2WI  
  • 8. Normal Imaging Anatomy of Brain Cerebral Hemisphere T1WI T2WI
  • 9. Normal Imaging Anatomy of Brain FL CS LF PL SSSSECTION AT CENTRUM SEMIOVALEFrontal lobe Centrum semiovale Parietal lobe Longitudinal fissure Superior sagittal sinus
  • 10. Normal Imaging Anatomy of Brain Basal GangliaClusters of neurons, located deep in the brain Caudate nucleus, putamen, globus pallidus, substantia nigraCT and MR finding Basal ganglia and Thalamus — gray matter density/intensity Internal and External capsule— white matter density/intensity
  • 11. Normal Imaging Anatomy of Brain
  • 12. Normal Imaging Anatomy of Brain IC CNH PU EC TH FCSECTION AT BASAL GANGLIONCaudate Nucleus Head Putamen Thalamus Internal Capsule External Capsule Falx Cerebri
  • 13. Normal Imaging Anatomy of Brain IC CNH PU EC TH FCSECTION AT BASAL GANGLIONCaudate Nucleus Head Putamen Thalamus Internal Capsule External Capsule Falx Cerebri
  • 14. Normal Imaging Anatomy of Brain Brain StemMid-brain, pons and medulla oblongataCT appearance Brain stem nuclei not identifiable Surrounded by fluid-density cisternMR finding Brain stem nuclei Mildly hypointense on T1WI, hyperintense on T2WI White matter fiber—a slightly high intensity signal Mildly hyperintense on T1WI, hypointense on T2WI
  • 15. Normal Imaging Anatomy of Brain GR SF OC HI MB AS SCV OLSECTION AT OPTICAL CHIASM Gyrus Rectus Sylvian Fissure Hippocampus Mid-brain Aqueduct of Sylvius Optical Chiasm Occipital L S. Cerebellar Vermis
  • 16. Normal Imaging Anatomy of Brain CerebellumCT appearance Gray and white matter can be distinguished Cerebellar tonsils and vermis slightly denser than other partsMR finding Signals of cortex, medulla and nuclei similar to those of brain
  • 17. Normal Imaging Anatomy of Brain TL TN PO FV CH OLSECTION AT FOURTH VENTRICLEOccipital Lobe Cerebellar Hemisphere Pons Temporal Lobe Trigeminal Nerve Fourth Ventricle
  • 18. Normal Imaging Anatomy of Brain
  • 19. SECTION AT MID-SAGITTAL PLANECC ThMb AS CePoMO FV Corpus callosum Thalamus Aqueduct of Sylvius Fourth Ven. Mid-brain Pons  Cerebellum Medulla oblongata
  • 20. SECTION AT LATERAL & THIRD VEN.LV CCINTL TV Lateral Ven. Third Ven. Corpus Callosum Insula Temporal Lobe
  • 21. Normal Imaging Anatomy of Brain Cerebral Vasculature Internal Carotid Artery anterior cerebral artery and middle cerebral artery Basilar Artery posterior cerebral artery Communicating Artery anterior and posterior communicating arteries Cerebral Vein superior sagittal, transverse, straight, sigmoid sinuses inferior sagittal sinus, Vein of Galen
  • 22. Normal Imaging Anatomy of Brain
  • 23. Normal Imaging Anatomy of Brain ACA MCA PCA ICA BAInternal Carotid Artery Anterior CA Middle CA Posterior CA Basilar A. Anterior&Posterior Com. A
  • 24. Normal Imaging Anatomy of Brain
  • 25. Normal Imaging Anatomy of Brain Superior Sagittal Sinus Straight Sinus ConfluenceInferior of sinusesSagittal Sinus Sigmoid Sinus Transverse Sinuse
  • 26. Normal Imaging Anatomy of Brain
  • 27. Basic Features of Brain Lesions HydrocephalusThe term hydrocephalus is derived from the Greek words"hydro" meaning water and "cephalus" meaning headAs the name implies, it is a condition in which the primarycharacteristic is excessive accumulation of fluid in the brainThe excessive accumulation of CSF results in an abnormalwidening of spaces in the brain called ventriclesThis widening creates potentially harmful pressure on thetissues of the brain
  • 28. Normal CSF flow passageLateral V – (Foramina ofMonro) – Third V –(Aqueduct of Sylvius) –Fourth V – (Medianaperture & LuschkaForamina) – SubarachnoidSpace – (ArachnoidGranulations) – Superior SS
  • 29. Basic Features of Brain Lesions HydrocephalusClassificationNon-communicatingCommunicating
  • 30. Basic Features of Brain Lesions HydrocephalusNon-communicating Hydrocephalus Obstructive hydrocephalus CSF-flow obstruction ultimately preventing CSF from flowing into subarachnoid space Secondary to congenital, infectious or tumor diseases Dilation of Ventricles above obstruction Ventricles normal below obstruction
  • 31. Basic Features of Brain Lesions HydrocephalusCommunicating Hydrocephalus Impaired CSF re-absorption in the absence of any CSF-flow obstruction btw ventricles Secondary to subarachnoid inflammation, craniocerebral injury, intracranial hemorrhage and brain tumors Ventricles and cisterns ubiquitously enlarged
  • 32. Communicating Hydrocephalus
  • 33. Basic Features of Brain Lesions Brain Atrophy Reduction in brain tissue volume Secondary to expansion of the cranial CSF volume Caused by Normal Aging and diseases Diffused brain atrophy and localized brain atrophy
  • 34. Basic Features of Brain Lesions Necrosis and cystic degeneration Lack of blood supply or interruption of blood flow Tissue necrosis and liquefaction-cystic degeneration Commonly found in tumor
  • 35. Basic Features of Brain Lesions Calcification Physiological Calcification Pineal calcification Age-related basal ganglia calcification Pathological calcification Calcification of craniopharyngioma Calcification of gliomas Calcification of meningioma
  • 36. CHONDROMA MENINGIOMA
  • 37. Basic Features of Brain Lesions Mass effect Structure departed from normal position due to intracranial lesion Commonly found in tumors, hematoma, infarction, abscess, etc
  • 38. Basic Features of Brain Lesions Mass effectSigns of supratentorial space-occupying Displaced or compressed ventricle Narrowing or occlusion of ipsilateral cerebral sulcus and cistern Shift of midline structuresSigns of infratentorial space-occupying Deformation and shift of fourth ventricle and brainstem Ventricular dilatation caused by CSF pathway obstruction
  • 39. Brain Tumor Intra-axial tumorPrimary Glioma 40 % ~50 % 70 %— Astrocytoma Angioma Medulloblastoma LymphomaSecondary Metastatic
  • 40. Brain Tumor Intra-axial tumorAstrocytoma The most common type of gliomas At any age, most commonly between the ages of 20- 40 Supratentorial predominantly for adult, infratentorial for children Present with seizures or focal neurological deficits, headache and increased intracranial pressure Graded from I to IV based on histological differentiation
  • 41. Brain Tumor Intra-axial tumorAstrocytoma Grade 1 Malignant astrocytomaLower density on CT Heterogeneous densityLong T1 and long T2 intensity Mixed signal intensitySlight mass effect Marked mass effectMild surrounding edema Severe surrounding edemaWell-demarcated boundary Ill-demarcated boundaryNo post-contrast enhancement Post-contrast enhancement
  • 42. Astrocytoma Grade 1
  • 43. Astrocytoma Grade 2
  • 44. Astrocytoma Grade 2
  • 45. Glioblastoma multiforme(Malignant)
  • 46. Brain Tumor Intra-axial tumorBrain Metastases Via blood stream route Most commonly from lung cancer Imaging features Multiple nodules Necrosis-frequently seen Solitary nodule-rarely Lower density, hypointense on T1WI, hyperintense on T2WI Massive peri-nodular edema Substantial post-contrast enhancement
  • 47. 60Y/FLung Adenocarcinoma
  • 48. Neoplasm, metastasis, renal cell primary
  • 49. Brain Tumor Extra-axial tumor(1)MeningiomaThe most common tumor outside the brainOriginate from arachnoid villi cellsThe clinical symptomsare closely related to the exact site of the tumorSolid tumors most commonly. Adjacent skull is showed reactive hyperplasia or bone destructionCT appearance Iso-density or slight low-density. Somtimes with calcificationMR finding Isointense/slight hypointense on T1WI , slight hyperintense onT2WI High vascularized in or arround tumorsEnhancement significant
  • 50. Brain Tumor Extra-axial tumorMeningioma The most common extracerebral tumor Originate from arachnoid villi cells Clinical symptoms closely related to site of tumor Most are solid texture Adjacent skull shown reactive hyperplasia or bone destruction
  • 51. Brain Tumor Extra-axial tumorAcoustic neurinoma High incidence, lower than that of meningioma Located in the internal auditory canal Combined with hemorrhage and cystic degeneration No calcification, Iso-/ slight hyperdense on CT Iso-/hypointense on T1WI and hyperintense on T2WI Enlarged internal auditory canal Post-contrast enhancement on both CT and MRI
  • 52. Neoplasm, schwannoma, cerebellopontine angle
  • 53. Cerebrovascular DiseaseHypertensive intracerebral hemorrhage (HIH)Intracranial aneurysmBrain infarction
  • 54. Cerebrovascular Disease HIHHypertensive intracerebral hemorrhage Location: most frequently striatum and internal capsule Etiology: chronic hypertension
  • 55. Cerebrovascular Disease HIHCT appearan A ellipse -shaped high-density mass Surrounding edema Hemorrhage breaking into ventricle Mass effect Cerebral hernia
  • 56. Cerebrovascular Disease HIHMR finding Signal intensity of intracerebral hemorrhage changes with theevolution of hemoglobin Super-acute stage (within 6h) Isointense or lower signal on T1WI, Hyperintense on T2WI Acute stage (7h~3d) Isointense or lower signal on T1WI, Hypointense on T2WI Subacute stage (4d~4w) Hyperintense on T1WI, Central isointensity or hypointensitysurrounded by hyperintensity on T2WI
  • 57. 14 D later
  • 58. 2 days after first CT
  • 59. Acute stage intracerebral hemorrhage
  • 60. 16 D later
  • 61. Cerebrovascular disease2 、 Intracranial aneurysm Congenital aneurysmAssociated with arterial fibro- muscular dysplasia or absenceOften occur in branches of the Circle of Willis , in particular at the arterial bifurcation Acquired aneurysm Traumatic Infection Atherosclerosis Easily mistaken for tumor to surgical resection
  • 62. Cerebrovascular Disease Intracranial AneurysmIntracranial aneurysm Aneurysm rupture Severe headache is the most common symptom Depends on size, morphology and high blood pressure CT—subarachnoid hemorrhage, with intramural calcification Aneurysm Flow void sign on T1WI and T2WI MRA helps to find medium-size aneurysms Small aneurysms are confirmed by DSA
  • 63. Internal carotidartery aneurysm
  • 64. Internal carotid-siphon aneurysm
  • 65. Cerebrovascular Disease Brain InfarctionBrain Infarction Caused by arterial occlusion Signs and symptoms vary with vessel involved and collateral circulation available. Most commonly, sudden hemiplegia, aphasia Neuronal eosinophilic degen.and nuclear pyknosis 4 h after attack Nuclear necrosis starts within 15~24h Phagocytic cells emerge within 2~3d Reactive astrocytosis and capillary hyperplasia 1w after onset
  • 66. Cerebrovascular Disease Brain InfarctionCT appearance The gray and white matter junctions vanish within 3h. No positive-findings within 24h Direct-Signs:low-density Indirect signs: gyri swelling, sulci disappearing, ventricular compression Hemorrhage occurs due to reperfusion injury in infarction
  • 67. Cerebrovascular Disease Brain InfarctionMR finding Long T1 and long T2 signal intensity Diffusion Weighted Imaging (DWI) can identify cerebral infarction within 1 hour after onset Acute stage: Enhancement of vessel Subacute stage: Typical enhancement of gyri Perfusion MRI can display the ischemic core and penumbra MRA can demonstrate the corresponding arterial disorders
  • 68. Traumatic Brain InjuryEpidural hematomaSubdural hematomaAcute contusion and laceration
  • 69. Traumatic Brain Injury Epidural HematomaEpidural Hematoma Caused by rupture of blood vessels and dural artery Accumulation of blood in space btw inner plate and dura mater Temporo-parietal lobe the most commonly involved Not cross suture lines, mostly unilateral Dura mater adheres skull so firmly that hematoma is confined and shuttle-shaped Acompanied with fracture, but no intraparenchymal injury
  • 70. Traumatic Brain Injury Epidural HematomaCT appearance Confined shuttle-shaped or biconvex-shaped high density beneath the inner plate Adjacent skull fracture, cerebral edema, midline deviation
  • 71. Traumatic Brain Injury Epidural HematomaMR finding Morphological alteration similar to CT Signal intensity depends on changes of hemoglobin over time Acute stage(~3D): Isointense on T1WI, Hypointense on T2WI Subacute stage(4D~3W): Hyperintense on T1WI and T2WI Chronic stage(3W~): Hyperintense on T1WI and T2WI
  • 72. Acute epidural hematoma, fusiform high density beneath Frontoparietal boneplate (white arrow) , liquid-plane (black arrow) Fracture in bone window ( white arrow)
  • 73. MRI Acute stage epidural hematoma
  • 74. Traumatic Brain Injury Subdural HematomaSubdural Hematoma Caused by rupture of cortical A and V or bridging veins Accumulation of blood in space btw dura and arachnoid Typically, hematoma crescent-shaped Staging of subdural hematoma similar to that of epidural Hem. Acute stage Subacute stage Chronic stage High-density High-/Isodensity Low-density
  • 75. Traumatic Brain Injury Subdural HematomaCT appearance Acute stage Crescent-shaped high density beneath inner skull plate Accompanied with cerebral contusion, subarachnoid hemorrhage, significant mass effect Subacute stage Crescent-shaped high density or isodensity Inward shift of the gray and white matter junctions on the affected side, sulci disappear, ventricle deformation Chronic stage Crescent-shaped low density
  • 76. Acute stage subdural hematoma , banded high density beneath theskull plate in left frontoparietal (black arrow)
  • 77. Traumatic Brain Injury Subdural HematomaMR findingStaged signal intensity stage T1WI T2WI Acute stage Isointense Hypointense /HyperintenseSubacute stage Hyperintense HyperintenseChronic stage Hyperintense Hyperintense surrounded by hypointense ring
  • 78. MRI Subacute stage subdural hematoma, cortical vein is strippedfrom the skull
  • 79. Traumatic Brain Injury Subdural HematomaCT vs MRI CT MRI CT Acute stage High desity Isointense Advantage CT MRI MRI Subacute stage Iso-density Hyperintense Advantage CT MRI MRI Chronic stage Low density Hyperintense Advantage Like CSF
  • 80. Subacute stage subdural hematomaCT :compression displacement ofthe right occipito-temporal sulcusMRI : hyperintenseFLAIR :subarachnoid hemorrhageMRI is superior to CT in displayiso-density hematoma
  • 81. 1 M laterSubdural hematoma (isodense to brain)1
  • 82. 17 D later
  • 83. Traumatic Brain Injury Contusion and Laceration3 、 Acute contusion and laceration of brain Damage occurs at (and sometimes opposite) the point of impact—the contact part of the gyri with the skull
  • 84. Traumatic Brain Injury Contusion and LacerationAcute contusion and laceration of brain Pathology: regional cerebral edema, necrosis, liquefying, bleeding foci Clinical symptoms: headache, nausea, vomiting, disturbance of consciousness
  • 85. Traumatic Brain Injury Contusion and LacerationCT appearanceLow density edema with multiple scattered microhemorrhages mass effect, subarachnoid hemorrhage, subdural hematomaMild cerebral contusion can be absorbed
  • 86. Acute cerebral contusion, there are low-density edema withflake high-density shadow(Asterisk), accompanied withsubarachnoid hemorrhage in the suprasellar pool, sylvian cistern andaround the right falx cerebri(black arrow). The gas in the suprasellarpool indicates basal skull fractures(black arrowhead).
  • 87. Traumatic Brain Injury Contusion and LacerationMR findingAcute and subacute cerebral contusion and laceration multiple areas of mixed signalChronic cerebral contusion and laceration edema and mass effect reduced, malacia, brain atrophy
  • 88. IR/T2WI , Oxyhaemoglobin in HematomaIsointense , Edema with mass effect
  • 89. Acute cerebral contusionIntracerebral hemorrhage andsubarachnoid hemorrhageMRI is superior to CT in showingsubarachnoid hemorrhage
  • 90. questionsHeadache 4 monthsNo traumatic history
  • 91. Acute onset of headacheHypertension for 10 years
  • 92. 15 D later Acute onset of left hand numbnessCT 1
  • 93. MRI 2
  • 94. Subacute hemorrhage

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