Diagnostic Neuroradiology
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Diagnostic Neuroradiology

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Diagnostic Neuroradiology Presentation Transcript

  • 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
    • P ia mater  
  • 4. Falx cerebri Tentorium cerebelli Normal Imaging Anatomy of Brain Meninges
  • 5. Falx cerebri Dura mater Arachnoid Subarachnoid space Pia mater Arachnoid granulation S. sagittal sinus Normal Imaging Anatomy of Brain Meninges
  • 6. Normal Imaging Anatomy of Brain Meninges Falx and Tentorium Iso-/-mildly hyperdense compared with cortex on CT Hyperdense when calcified Markedly enhanced after iodine contrast Hypointense in T 1 WI and T 2 WI Homogeneity in signal intensity Markedly enhanced after Gadolinium
  • 7. Normal Imaging Anatomy of Brain Cerebral Hemisphere
    • The layer of gray matter cover s 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 T 1 WI
    • Gray matter hyperintense than white matter on T 2 WI  
  • 8. T 1 WI T 2 WI Normal Imaging Anatomy of Brain Cerebral Hemisphere
  • 9. Frontal lobe Centrum semiovale Parietal lobe Longitudinal fissure Superior sagittal sinus FL CS PL LF SSS SECTION AT CENTRUM SEMIOVALE Normal Imaging Anatomy of Brain
  • 10. Normal Imaging Anatomy of Brain Basal Ganglia Clusters of neurons, located deep in the brain Caudate nucleus, putamen, globus pallidus, substantia nigra CT 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. SECTION AT BASAL GANGLION Caudate Nucleus Head Putamen Thalamus I nternal Capsule External Capsule Falx Cerebri Normal Imaging Anatomy of Brain CNH PU EC FC TH IC
  • 13. Caudate Nucleus Head Putamen Thalamus I nternal Capsule External Capsule Falx Cerebri SECTION AT BASAL GANGLION Normal Imaging Anatomy of Brain CNH PU EC FC TH IC
  • 14. Normal Imaging Anatomy of Brain Brain Stem Mid-brain, pons and medulla oblongata CT appearance Brain stem nuclei not identifiable Surrounded by fluid-density cistern MR finding B rain stem nuclei Mildly hypointense on T 1 WI, hyperintense on T 2 WI White matter fiber— a slightly high intensity signal M ildly hyperintense on T 1 WI, hypointense on T 2 WI
  • 15. SECTION AT OPTICAL CHIASM Gyrus Rectus Sylvian Fissure Hippocampus  Mid- brain Aqueduct of Sylvius Optical Chiasm Occipital L  S. Cerebellar Vermis Normal Imaging Anatomy of Brain GR OC MB OL SF HI AS SCV
  • 16. Normal Imaging Anatomy of Brain Cerebellum CT appearance Gray and white matter can be distinguished Cerebellar tonsils and vermis slightly denser than other parts MR finding Signals of cortex, medulla and nuclei similar to those of brain  
  • 17. SECTION AT FOURTH VENTRICLE Occipital Lobe Cerebellar Hemisphere Pons Temporal Lobe Trigeminal Nerve Fourth Ventricle Normal Imaging Anatomy of Brain PO CH OL TL TN FV
  • 18. Normal Imaging Anatomy of Brain
  • 19. Corpus callosum Thalamus Aqueduct of Sylvius Fourth Ven. Mid-brain Pons   Cerebellum Medulla oblongata SECTION AT MID-SAGITTAL PLANE Th AS Ce FV CC Mb Po MO
  • 20. Lateral Ven. Third Ven. Corpus Callosum Insula Temporal Lobe LV IN TL CC TV SECTION AT LATERAL & THIRD VEN.
  • 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. Internal Carotid Artery Anterior CA Middle CA Posterior CA Basilar A. Anterior&Posterior Com. A Normal Imaging Anatomy of Brain ICA MCA PCA BA ACA
  • 24. Normal Imaging Anatomy of Brain
  • 25. Superior Sagittal Sinus Straight Sinus Confluence of sinuses Inferior Sagittal Sinus Normal Imaging Anatomy of Brain Transverse Sinuse Sigmoid Sinus
  • 26. Normal Imaging Anatomy of Brain
  • 27.  
  • 28. Basic Features of Brain Lesions Hydrocephalus The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain The excessive accumulation of CSF results in an abnormal widening of  spaces in the brain called ventricles This widening creates potentially harmful pressure on the tissues of the brain
  • 29.  
  • 30. Normal CSF flow passage Lateral V – (Foramina of Monro) – Third V – (Aqueduct of Sylvius) – Fourth V – (Median aperture & Luschka Foramina) – Subarachnoid Space – (Arachnoid Granulations) – Superior SS
  • 31.  
  • 32. Classification Non-communicating Communicating Basic Features of Brain Lesions Hydrocephalus
  • 33.
    • Non-communicating Hydrocephalus
    • Obstructive hydrocephalus
    • CSF-flow obstruction ultimately preventing CSF from flowing
    • into subarachnoid space
    • Secondary to congenital, infectious or tumor diseases
    • D ilation of Ventricles above obstructi on
    • Ventricles normal below obstructi on
    Basic Features of Brain Lesions Hydrocephalus
  • 34.  
  • 35.  
  • 36.
    • Communicating Hydrocephalus
    • Impaired CSF re-absorption in the absence of any CSF-flow
    • obstruction btw ventricles
    • Secondary to s ubarachnoid inflammation, craniocerebral injury,
    • intracranial hemorrhage and brain tumors
    • V entricles and cisterns ubiquitously enlarged
    Basic Features of Brain Lesions Hydrocephalus
  • 37. Communicating Hydrocephalus
  • 38.  
  • 39.
    • Reduction in brain tissue volume
    • Secondary to expansion of the cranial CSF volume
    • Caused by Normal Aging and diseases
    • D iffused brain atrophy and l ocalized brain atrophy
    Basic Features of Brain Lesions Brain Atrophy
  • 40.  
  • 41.  
  • 42.
    • Lack of blood supply or interruption of blood flow
    • Tissue necrosis and liquefaction-cystic degeneration
    • Commonly found in tumor
    Basic Features of Brain Lesions Necrosis and cystic degeneration
  • 43.  
  • 44.  
  • 45.
    • Physiological Calcification
    • Pineal calcification
    • Age-related basal ganglia calcification
    • Pathological calcification
    • Calcification of craniopharyngioma
    • Calcification of gliomas
    • Calcification of meningioma
    Basic Features of Brain Lesions Calcification
  • 46. CHONDROMA MENINGIOMA
  • 47.
    • Structure departed from normal position due to intracranial lesion
    • Commonly found in tumors, hematoma, infarction, abscess, etc
    Basic Features of Brain Lesions Mass effect
  • 48.
    • Signs of supratentorial space-occupying  
    • Displaced or compressed ventricle
    • Narrowing or occlusion   of ipsilateral cerebral sulcus and cistern
    • Shift of midline structures
    • Signs of infratentorial space-occupying
    • Deformation and shift of fourth ventricle and brainstem
    • Ventricular dilatation caused by CSF pathway obstruction
    Basic Features of Brain Lesions Mass effect
  • 49.  
  • 50.  
  • 51.
    • Primary
    • Glioma 40 % ~50 %
    • 70 %— Astrocytoma
    • A ngioma
    • Medulloblastoma
    • Lymphoma
    • Secondary
    • Metastatic
    Brain Tumor I ntra-axial tumor
  • 52.
    • Astrocytoma
    • The most common type of gliomas
    • A t any age, most commonly between the ages of 20 - 40
    • S upratentorial predominantly for adult, infratentorial for children
    • P resent with seizures or focal neurological deficits, headache and increased intracranial pressure
    • G raded from I to IV based on histological differentiation
    Brain Tumor I ntra-axial tumor
  • 53.
    •   Astrocytoma Grade 1
    •   Lower density on CT
    • Long T 1 and long T 2 intensity
    • Slight mass effect
    • Mild surrounding edema
    • Well-demarcated boundary
    • No post-contrast enhancement
    • Malignant astrocytoma
    • Heterogeneous density
    • Mixed signal intensity
    • Marked mass effect
    • Severe surrounding edema
    • Ill-demarcated boundary
    • Post-contrast enhancement
    Brain Tumor I ntra-axial tumor
  • 54. Astrocytoma Grade 1
  • 55. Astrocytoma Grade 2
  • 56. Astrocytoma Grade 2
  • 57. Glioblastoma multiforme(Malignant)
  • 58.
    • Brain Metastases
    • Via blood stream route
    • M ost commonly from lung cancer
    • Imaging features
    • M ultiple nodules
    • Necrosis- frequently seen
    • S olitary nodule- rarely
    • Lower dens ity , hypointense on T 1 WI, hyperintense on T 2 WI
    • Massive peri-nodular edema
    • Substantial post-contrast e nhancement
    Brain Tumor I ntra-axial tumor
  • 59. 60Y/F Lung Adenocarcinoma
  • 60. Neoplasm, metastasis, renal cell primary
  • 61.
    • (1)Meningioma
    • The most common tumor outside the brain
    • Originate from arachnoid villi cells
    • The clinical symptomsare closely related to the exact site of the tumor
    • Solid tumors most commonly. A djacent skull is showed reactive hyperplasia or bone destruction
    • CT appearance
    • Iso-density or slight low-density. Somtimes with calcification
    • MR finding
    • Isointense/slight hypointense on T 1 WI , slight hyperintense onT 2 WI
    • H igh vascularized in or arround tumors
    • E nhancement significant
    Brain Tumor Ex tra-axial tumor
  • 62.
    • Meningioma
    • The most common extracerebral tumor
    • Originate from arachnoid villi cells
    • Clinical symptoms closely related to site of tumor
    • Most are solid texture
    • A djacent skull shown reactive hyperplasia or bone destruction
    Brain Tumor Ex tra-axial tumor
  • 63.  
  • 64.  
  • 65.  
  • 66.
    • Acoustic neurinoma
    • High incidence, lower than that of meningioma
    • Located in the internal auditory canal
    • C ombined with hemorrhage and cystic degeneration
    • No calcification , Iso-/ slight hyperdense on CT
    • Iso-/hypointense on T 1 WI and hyperintense on T 2 WI
    • Enlarged internal auditory canal
    • Post-contrast e nhancement on both CT and MRI
    Brain Tumor Ex tra-axial tumor
  • 67. Neoplasm, schwannoma, cerebellopontine angle
  • 68.  
  • 69.  
  • 70.
    • Hypertensive intracerebral hemorrhage (HIH)
    • Intracranial aneurysm
    • Brain infarction
    Cerebrovascular Disease
  • 71.
    • Hypertensive intracerebral hemorrhage
    • Location: most frequently striatum and internal capsule
    • Etiology: chronic hypertension
    Cerebrovascular Disease HIH
  • 72.
    • CT appearan
    • A e llipse -shaped high-density mass
    • Surrounding edema
    • Hemorrhage breaking into ventricle
    • Mass effect
    • C erebral hernia
    Cerebrovascular Disease HIH
  • 73.  
  • 74.
    • MR finding
    • Signal intensity of intracerebral hemorrhage changes with the
    • evolution of hemoglobin
    • Super-acute stage (within 6h)
    • Isointense or lower signal on T 1 WI, Hyperintense on T 2 WI
    • Acute stage (7h~3d)
    • Isointense or lower signal on T 1 WI, Hypointense on T 2 WI
    • Subacute stage (4d~4w)
    • Hyperintense on T 1 WI, Central isointensity or hypointensity
    • surrounded by hyperintensity on T 2 WI
    Cerebrovascular Disease HIH
  • 75. 14 D later
  • 76. 2 days after first CT
  • 77. Acute stage intracerebral hemorrhage
  • 78. 16 D later
  • 79.
    • 2 、 Intracranial aneurysm
    • Congenital aneurysm
    • A ssociated with arterial fibro- muscular dysplasia or absence
    • Often occur in branches of the Circle of Willis , in particular at the arterial bifurcation
    • Acquired aneurysm
    •      Traumatic
    •      I nfection
    •      Atherosclerosis
    • E asily mistaken for tumor to surgical resection
    Cerebrovascular disease
  • 80.
    • Intracranial 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 T 1 WI and T 2 WI
    •      MRA helps to find medium-size aneurysms
    • S mall aneurysms are confirmed by DSA
    Cerebrovascular Disease Intracranial Aneurysm
  • 81. Internal carotid artery aneurysm
  • 82. Internal carotid-siphon aneurysm
  • 83.
    • Brain Infarction
    • Caused by arterial occlusion
    • Signs and symptoms vary with vessel involved and collateral
    • circulation available. Most commonly, sudden hemiplegia, aphasia
    • N euronal eosinophilic degen.and nuclear pyknosis 4 h after attack
    • Nuclear n ecrosis starts within 15~24h
    • Phagocytic cells emerge within 2~3d
    • Reactive astrocytosis and capillary hyperplasia 1w after onset
    Cerebrovascular Disease Brain Infarction
  • 84.
    • CT appearance
    • The gray and white matter junctions vanish within 3h.
    • No positive-findings within 2 4h
    • Direct-Signs:low-density
    • I ndirect signs: gyri swelling, sulci disappearing,
    • ventricular compression
    • Hemorrhage occurs due to reperfusion injury in infarction
    Cerebrovascular Disease Brain Infarction
  • 85.
    • MR finding
    • L ong T 1 and long T 2 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
    Cerebrovascular Disease Brain Infarction
  • 86.  
  • 87.  
  • 88.  
  • 89.  
  • 90.  
  • 91.
    • Epidural hematoma
    • Subdural hematoma
    • Acute contusion and laceration
    Traumatic Brain Injury
  • 92.
    • Epidural 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
    Traumatic Brain Injury Epidural Hematoma
  • 93.
    • CT appearance
    •     
    • Confined shuttle-shaped or biconvex-shaped high density beneath the inner plate
    •     
    • Adjacent skull fracture, cerebral edema, midline deviation
    Traumatic Brain Injury Epidural Hematoma
  • 94.
    • MR finding
    • Morphological alteration similar to CT
    • Signal intensity depends on changes of hemoglobin over time
    • Acute stage(~3D): Isointense on T 1 WI, Hypointense on T 2 WI
    • Subacute stage(4D~3W): Hyperintense on T 1 WI and T 2 WI
    • Chronic stage(3W~): Hyperintense on T 1 WI and T 2 WI
    Traumatic Brain Injury Epidural Hematoma
  • 95. Acute epidural hematoma, fusiform high density beneath Frontoparietal bone plate (white arrow) , liquid-plane (black arrow) Fracture in bone window ( white arrow)
  • 96. MRI Acute stage epidural hematoma
  • 97.  
  • 98.
    • Subdural 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.
    Traumatic Brain Injury Subdural Hematoma Acute stage Subacute stage Chronic stage High-density High-/Isodensity Low-density
  • 99.
    • CT 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
    Traumatic Brain Injury Subdural Hematoma
  • 100. Acute stage subdural hematoma , banded high density beneath the skull plate in left frontoparietal (black arrow)
  • 101.
    • MR finding
    • Staged signal intensity
    Traumatic Brain Injury Subdural Hematoma stage T 1 WI T 2 WI Acute stage Isointense /Hyperintense Hypointense Subacute stage Hyperintense Hyperintense Chronic stage Hyperintense Hyperintense surrounded by hypointense ring
  • 102. MRI Subacute stage subdural hematoma , cortical vein is stripped from the skull
  • 103. CT vs MRI Traumatic Brain Injury Subdural Hematoma Acute stage CT High desity MRI Isointense CT Advantage Subacute stage CT Iso-density MRI Hyperintense MRI Advantage Chronic stage CT Low density Like CSF MRI Hyperintense MRI Advantage
  • 104. Subacute stage subdural hematoma CT : compression displacement of the right occipito-temporal sulcus MRI : hyperintense FLAIR : subarachnoid hemorrhage MRI is superior to CT in display iso-density hematoma
  • 105. Subdural hematoma (isodense to brain)1 1 M later
  • 106. 17 D later
  • 107.
    • 3 、 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
    Traumatic Brain Injury Contusion and Laceration
  • 108.
    • Acute contusion and laceration of brain
    • Pathology: regional cerebral edema, necrosis, liquefying, bleeding foci
    • Clinical symptoms: headache, nausea, vomiting, disturbance of consciousness
    Traumatic Brain Injury Contusion and Laceration
  • 109.
    • CT appearance
    • Low density
    • edema with multiple scattered microhemorrhages
    • mass effect, subarachnoid hemorrhage, subdural hematoma
    • Mild cerebral contusion can be absorbed
    Traumatic Brain Injury Contusion and Laceration
  • 110. Acute cerebral contusion, there are low-density edema with flake high-density shadow(Asterisk), accompanied with subarachnoid hemorrhage in the suprasellar pool, sylvian cistern and around the right falx cerebri(black arrow). The gas in the suprasellar pool indicates basal skull fractures(black arrowhead).
  • 111.
    • MR finding
    • Acute and subacute c erebral contusion and laceration
    • multiple areas of mixed signal
    • Chronic c erebral contusion and laceration
    • edema and mass effect reduced, malacia, brain atrophy
    Traumatic Brain Injury Contusion and Laceration
  • 112. IR/T2WI , Oxyhaemoglobin in Hematoma Isointense , Edema with mass effect  
  • 113. Acute c erebral contusion Intracerebral hemorrhage and subarachnoid hemorrhage MRI is superior to CT in showing subarachnoid hemorrhage
  • 114.  
  • 115.  
  • 116. questions Headache 4 months No traumatic history
  • 117. Acute onset of headache Hypertension for 10 years
  • 118. Acute onset of left hand numbness CT 1 15 D later
  • 119. MRI 2
  • 120. Subacute hemorrhage