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- 2. • Imaging in Stroke • Imaging in Craniofacial Trauma • Non-traumatic Vascular Lesions • Infection and Inflammation • Demyelinating Diseases • Neoplasms, Cysts, and Tumor-like Lesions • Toxic, Metabolic, Degenerative Disorders • Congenital Malformations of the Skull and Brain
- 3. • Imaging in Stroke • Imaging in Craniofacial Trauma • Common Neoplasms
- 4. Stroke • Clinical event characterized by sudden onset of a neurologic deficit. • Ischemic stroke / infarction • Spontaneous/ non-traumatic primary intracranial hemorrhage
- 5. Stroke • Infarction • Permanent injury • Tissue perfusion is decreased long enough to result in necrosis (arterial occlusion) • Transient ischemic attack • Transient neurologic symptoms / signs • < 24 hours • Hemorrhage • Blood ruptures through arterial wall, spilling into the surrounding parenchyma, subarachnoid spaces, and ventricles
- 6. Stroke • Ischemia • Thromboembolic disease d/t atherosclerosis (PRINCIPAL CAUSE) • Larger artery atherosclerosis, cardioembolism, lacunes (small vessel occlusions) • Non-atherosclerotic causes • Vasculopathies, migraine headache, systemic/metabolic events (hypoxia) • Younger patients
- 7. Stroke • Spontaneous parenchymal hemorrhage • Hypertension (deep gray matter - basal ganglia and thalamus), brainstem and cerebellum • Infarcts, drug-induced (cocaine), anticoagulation • Cerebral amyloid angiopathy (> 50 years) • Venous thrombosis, neoplasm, vascular abnormalities
- 8. Stroke Goals of Acute Stroke Imaging • Establish a diagnosis as EARLY as possible • Ischemia / hemorrhage • Obtain accurate information about the intracranial vasculature and brain perfusion for guidance in selection of APPROPRIATE THERAPY.
- 9. Stroke • CT • Widely available • Quick • May be done without IV contrast • MRI • More sensitive and more specific for detection of acute ischemia • More sensitive in detection of small vessel and brainstem ischemia
- 10. Stroke • BRAIN ATTACK PROTOCOL • Begin with NECT (infarction/hemorrhage) • CTA (when hemorrhage is excluded) • CT or MR Perfusion studies (determine part of the brain that is irreversibly damaged and if there is a clinically relevant ischemic penumbra)
- 11. Stroke Ischemia • Hyperacute infarction (0-6 hours) • Normal or • Dense vessel sign - when there is embolic occlusion of a proximal vessel
- 12. Stroke Ischemia • Hyperacute infarction (0-6 hours) • Normal or • Dense vessel sign • Loss of gray matter density w/o mass effect
- 13. Stroke Ischemia • Acute infarction (6-36 hours): Cytotoxic and Vasogenic edema
- 14. Stroke Ischemia • Early subacute infarction (36 hours to 5 days): Reperfusion • Hemorrhagic transformation most commonly occurs during this phase • Contrast study: parenchymal enhancement in infarcted territory
- 15. Stroke Ischemia • Late Subacute infarction (5-14 days), Resolving Edema and Early Healing • CT fog effect
- 16. Stroke • Chronic Infarction (> 2 weeks) Healing • Edema has completely resolved • Dead neuronal tissue is removed and replaced by gliosis and cystic degeneration Ischemia
- 17. Stroke Spontaneous Parenchymal Hemorrhage • Imaging Appearance • NECT = Hyperdense • MRI = signal varies
- 18. Stroke • Appearance of Hemorrhage on MRI • Intrinsic biologic factors • Clot structure, RBC integrity and Hgb oxygenation • Extrinsic factors • Pulse sequence, field strength • T1 and T2 are most helpful in age estimation • T2* (GRE and SWI) most sensitive in detection of parenchymal hemorrhages
- 19. Stroke • Hematomas • Central core • Peripheral rim / boundary • Degradation of Hg begins in the periphery and progresses centrally
- 20. • Hemoglobin degradation • Fully oxygenated Hgb (oxy-Hgb) - non paramagnetic ferrous iron • Converted to deoxyHgb • Metabolized to methemoglobin (met Hgb) - ferric iron • metHgb is released, resorbed • Conversion to hemosiderin and ferritin
- 21. Hyp • Hyperacute Hemorrhage • IC oxyHg
- 22. Stroke
- 23. Stroke • Acute Hemorrhage • Deoxy-Hg
- 24. Stroke • Early Subacute Hemorrhage • IC methemoglobin in the periphery, deoxyHg core
- 25. Stroke • Late Subacute Hemorrhage • EC metHg
- 26. Stroke • Late Subacute Hemorrhage • EC metHg
- 27. Stroke • Chronic Hemorrhage • Hemosiderin
- 28. Head Trauma • MC cause of death worldwide in children and young adults
- 29. Head Trauma • Clinical classification of brain trauma Table lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 30. Head Trauma How to Image? • Skull Radiograph • Able to demonstrate calvarial fractures • Cannot depict extraaxial hemorrhages and parenchymal injuries • NECT • Worldwide screening tool for imaging acute head trauma • Depicts both bone and soft tissue injuries
- 31. Head Trauma • CTA • Penetrating neck injury • Fractured foramen transversarium / facet subluxation on C-spine • Skull base fracture traverses carotid canal / dural venous sinus How to Image?
- 32. Head Trauma Traumatic Brain Injury • Primary Effects of CNS Trauma • Directly related to immediate impact damage • Scalp and skull injuries, extra-axial hemorrhage/ hematomas • Parenchymal and miscellaneous injuries • Secondary Effects • Complications resulting from the primary injury over time • Herniation syndromes, cerebral edema, ischemia, vascular injuries
- 33. Head Trauma Primary Effects of CNS Trauma • Scalp • Lacerations • Extend partially/entirely through scalp layers (skin, subcutaneous fibrofatty tissue, galea aponeurotica, loose areolar connective tissue, periosteum) Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 34. Head Trauma Primary Effects of CNS Trauma • Scalp • Lacerations • Focal discontinuity, soft tissue swelling, subcutaneous air Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 35. Head Trauma Primary Effects of CNS Trauma • Scalp
- 36. Head Trauma Primary Effects of CNS Trauma
- 37. Head Trauma Primary Effects of CNS Trauma • Scalp
- 38. Head Trauma Primary Effects of CNS Trauma • Scalp • NECT - heterogeneously hyperdense crescentic scalp mass, that crosses suture lines Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 39. Head Trauma Primary Effects of CNS Trauma • Facial Injuries • Periorbital contusions, subconjunctival hemorrhage, lacerations of the lips, mouth, and nose
- 40. Head Trauma Primary Effects of CNS Trauma • Skull Fractures • Linear skull fracture • Sharply marginated linear defect, typically involves inner and outer tables of the calvaria
- 41. Head Trauma Primary Effects of CNS Trauma • Skull Fractures • Depressed Skull Fracture • Fragments are displaced inward • Typically tear the underlying dura and archnoid; associated with cortical contusions, CSF leak to the subdural space Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 42. Head Trauma Primary Effects of CNS Trauma • Skull Fractures • Elevated Skull Fracture • Often combined with depressed fracture • Simultaneously lifts and rotates the fracture fragment Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 43. Head Trauma Primary Effects of CNS Trauma • Skull Fractures • Diastatic Fracture • Widens a suture or synchondrosis • Usually in association with a linear fracture that extends into a suture Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 44. Head Trauma Primary Effects of CNS Trauma • Skull Fractures • “Growing” Skull Fracture (posttraumatic leptomeningeal cyst / craniocerebral erosion) • Enlarging fracture that occurs near posttraumatic encephalomalacia Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 45. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • In any intracranial compartment, within any space, between any layers of the cranial meninges
- 46. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Epidural Hematoma (EDH) • Between the calvaria and outer (periosteal) layer of the dura • 90% - arterial = middle meningeal artery • > 90% - unilateral, supratentorial; directly adjacent to a skull fracture • MC site = squamous portion of the temporal bone
- 47. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Epidural Hematoma (EDH) • Biconvex / lens shaped extra-axial collection • Swirl sign - active, rapid bleeding with unretracted clot Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 48. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Epidural Hematoma (EDH) • Biconvex / lens shaped extra-axial collection • Swirl sign - active, rapid bleeding with unretracted clot Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 49. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Subdural Hematoma (SDH) - 2nd MC extraaxial hematoma • Between the inner border cell layer of the dura and the arachnoid • MC cause = TRAUMA • Bridging of cortical veins as they cros the subdural space to enter a dural venous sinus (SSS is the most common)
- 50. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Subdural Hematoma (SDH) • Crescent shaped extraaxial collection displacing the gray-white matter interface medially Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 51. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Traumatic Subarachnoid Hemorrhage - MC extra-axial hematoma • Tearing of cortical arteries and veins, rupture of contusions and lacerations into the contiguous subarachnoid space, choroid plexus bleeds with intraventricular hemorrhage • Predominantly perisylvian regions, anterioinferior frontal and temporal sulci, hemipsheric convexities
- 52. Head Trauma Primary Effects of CNS Trauma • Extra-axial Hemorrhages • Traumatic Subarachnoid Hemorrhage • Usually peripheral • Linear hyperdensities in sulci adjacent to cortical contusions or under epidural / subdural hematomas Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 53. Head Trauma Primary Effects of CNS Trauma • Parenchymal Injuries • Cerebral Contusions and Lacerations • MC intraaxial injury • MC - temporal lobes • Almost always multiple, bilateral Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 54. Head Trauma Primary Effects of CNS Trauma • Parenchymal Injuries • Diffuse Axonal Injury (Traumatic axonal stretch injury) • 2nd MC parenchymal injury • Discrepancy between clinical status and imaging findings • Most are not associated with a fracture • Cortical sparing Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 55. Head Trauma Primary Effects of CNS Trauma • Pneumocephalus • Gas within the intracranial cavity • MC cause = TRAUMA • MC location = subdural space (frontal) Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 56. Head Trauma Primary Effects of CNS Trauma • Pneumocephalus • Mount Fuji Sign • Tension pneumocephalus
- 57. CNS Neoplasms Table lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 58. CNS Neoplasms Table lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 59. CNS Neoplasms Table lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 60. CNS Neoplasms • Demographics • Peak incidence • Children < 5 years • 5th -7th decades
- 61. • Demographics • Prevalence of tumor type by location • Meninges - MC location of all intracranial tumors CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 62. • Demographics • Prevalence of tumor type by location • Meninges - MC location of all intracranial tumors • Meningioma - MC histologic subtype of primary CNS neoplasm CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 63. • Demographics • Prevalence of tumor type by age • Approximately half of adult tumors are primary neoplasms • Half are metastatic spread from extra-CNS tumors CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 64. • Demographics • MC malignant CNS neoplasm (regardless of age) • Glioblastoma CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 65. • Demographics • 0-4 years old • MC tumor type = embryonal neoplasm • MC OVERALL childhood cancers • Pilocytic astrocytoma • Embryonal tumors (MC - medulloblastoma) CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 66. Primary CNS Neoplasms • Meningioma • MC of all brain tumors • WHO • Meningioma • Benign, most common type • Meningioma variants • Benign (meningothelial fibrous, transitional, etc) and aggressive variants (atypical) • Most aggressive form - anaplastic (malignant) meningioma CNS Neoplasms
- 67. Primary CNS Neoplasms • Meningioma • Etiology • From progenitor cells that give rise to arachnoid meningothelial cells outside the thin arachnoid layer that covers the brain and spinal cord • Ionizing radiation CNS Neoplasms
- 68. Primary CNS Neoplasms • Meningioma • Location • 90% - supratentorial • 25% parasagittal • 20% convexity • 15-20% sphenoid ridge CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 69. • Meningioma • 90% are solitary • Association - NF2, multiple • Middle-aged to elderly (peak is 6th - 7th decades) • F > M CNS Neoplasms
- 70. • Meningioma • CT • Commonly mildy to moderately hyperdense to cortex • Peritumoral vasogenic edema • 25% have calcifications • Variable hyperostosis, enlargement of adjacent PNS (in skull base locations), bone lysis • Strong enhancement post-contrast CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 71. • Meningioma • MRI • Majority are isointense with cortex on all sequences • Some may show cyst formation / necrotic change • CSF vascular cleft • Enhancement • Surrounding edema • Calcifications CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 72. • Glioblastoma (IDH-Wild Type) • MC and most malignant of all astrocytomas • Location: subcortical and deep WM, easily spreads across the corpus callosum and corticospinal tracts • Symmetric involvement involvement of the corpus callosum - butterfly glioma pattern CNS Neoplasms
- 73. • Glioblastoma (IDH-Wild Type) • Peak age - 60-75 years • MC presentation - seizure, focal neurologic deficits, mental status changes, headache (elevated ICP) CNS Neoplasms
- 74. • Glioblastoma (IDH-Wild Type) • Imaging • MC - thick irregular enhancing rind of tumor surrounding a necrotic core • Hemorrhage is common • Marked mass effect, edema • Necrosis, cysts CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 75. • Glioblastoma (IDH-Wild Type) CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 76. • Pilocytic Astrocytoma • 5-10% of all gliomas • MC primary brain tumor in children • > 80% occur in patients under 20 • Peaks between 5-15 CNS Neoplasms
- 77. • Pilocytic Astrocytoma • MC location - cerebellum (60%) • 2nd MC site - in and around the optic N/chiasm and hypothalamus / 3rd ventricle • 3rd MC site - pons and medulla CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 78. • Pilocytic Astrocytoma • Imaging • MC appearance in the posterior fossa is a well-delineated cerebellar cyst with a mural nodule • Non ehancing cyst with a strongly enhancing mural nodule CNS Neoplasms Image lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 79. • Pilocytic Astrocytoma CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 80. • Medulloblastoma • 2nd MC overall pediatric brain tumor • MC malignant CNS neoplasm of childhood • > 80% arise in the midline (4th ventricle) CNS Neoplasms Diagram lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 81. • Medulloblastoma • Imaging • Moderately hyperdense, relatively well-defined mass in the midline posterior fossa • Cyst formation and calcification • Strong, heterogeneous enhancement CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 82. • Medulloblastoma CNS Neoplasms Images lifted from: Osborn’s Brain Imaging, Pathology, and Anatomy 2nd edition by Anne G. Osborn
- 83. • Metastases • MC infratentorial and supratentorial malignant neoplasm in adults • Usually well-defined, round masses near the gray-white junction • Show contrast enhancement, cause nodular/ring enhancement CNS Neoplasms
- 84. • Metastases • MC primary extracranial tumors in adults to metastasize to the brain • Lung and breast carcinomas • 3rd - melanoma CNS Neoplasms
- 85. • Metastases • Hemorrhage • Melanoma, RCC, choriocarcinoma, thyroid cancer CNS Neoplasms
- 86. • Metastases • Vasogenic Edema CNS Neoplasms