This document provides an overview of radiology for brain and spine imaging for radiation oncologists. It discusses various imaging modalities including CT, MRI, nuclear imaging and angiography. It describes key anatomical structures of the brain such as the meninges, ventricles, sulci and gyri, lobes, basal ganglia and cerebellum. Different MRI sequences are outlined including T1, T2, FLAIR, DWI and perfusion. Spine imaging including sequences for T1, T2, STIR and post-contrast are also reviewed. Important considerations for planning MRI such as field of view and disease-specific sequences are highlighted.

1. Radiology for Radiation Oncologist
Radiology of Brain & Spine
Dr Kanhu Charan Patro
MD,DNB[RADIATION ONCOLOGY],MBA,CEPC,PDCR
HOD, Radiation Oncology
MGCHRI, Visakhapatnam, INDIA
M +91 9160470564, drkcpatro@gmail.com 1

2. Flow
• Basics
• Identification
• Meninges
• Vessel
• White and gray matter
• Sulci and gyri
• Ventricles
• Calcification
• Lobes
• Functional areas
• Brain stem
• Cerebellum
• Basal ganglia
• Pineal gland
• Cisterns
• Pituitary
• Flax

3. BAISCS

4. What a radiation oncologist wants?
• Clear identification
• Target
• OAR
• Good resolution
4

5. Ammunitions
• CT
• Plain
• Contrast
• Cisternography
• CT Angio
• MRI
• Plain
• Contrast/Double Contrast/Triple contrast
• Cisternography
• MR Angio
• MRS
• Other Functional sequences
• Nuclear imaging
• DSA-Digital Subtraction Angiogram
5

6. Basics
• Slicing
• Windowing
• CT number
• Measuring the density
• Contrast
• FOV vs BORE
6

7. Slicing
7

8. Sagittal[s-s] Coronal[A-P] Axial[S-I]
Side view Front view Bottom up view
8

9. Slicing
9

10. Imaging planes
10

11. 11

12. A. Brightness refers to the overall lightness or
darkness of the image.
B. Contrast is the difference in brightness between
objects in the image.
12

13. Brightness- window level Contrast- window width
13

14. 14WIDTH
LEVEL

15. 15

16. Bore
16

17. FOV
• (FOV) The field of view is the
maximum diameter of the
area of the scanned object that is
represented in the reconstructed
image.
• FULL FOV
17

18. Describing the tissues/organs
Procedure Like brain Less than brain
Darker
More than brain
Whiter
CT SCAN Isodense Hypodense Hyperdense
MRI Isointense Hypointense Hyperintense
18

19. 19

20. Hounsfield unit
• CT number
• Different for different tissue
• Related to composition of tissue
20

21. 21

22. 22

23. 23

24. Contrast
24

25. Images
• Structural imaging refers to approaches that are specialized for the
visualization and analysis of anatomical properties of the brain.
• Functional magnetic resonance imaging, or fMRI, is a technique for
measuring brain activity. It works by detecting the changes in blood
oxygenation and flow that occur in response to neural activity
• Tractography is a 3D modeling technique used to visually represent nerve
tracts using data collected by diffusion MRI. It uses special techniques of
magnetic resonance imaging and computer-based diffusion MRI.
25

26. What is a Sequence?
• Sequence of events in MRI
machine
• By varying the sequence of RF
pulses applied & collected,
different types of images are
created
• PHILIPS
• GE
• TOSHIBA
• SIEMENS
• HITACHI
26

27. Playing with TR and TE and RF
27

28. 28

29. T1 sequence
•T1
•Fat bright[white]
•Water black
•Normal anatomy
•Vascular changes
29
w w

30. T1 contrast
• T1 contrast • T1 contrast
• Vessels -hyperintense
30

31. T2 sequence- Flip side of T1
•T2
• CSF, AQ/VT HUMOR WHITE
•Fat black/white mater
•Water white
•Blood vessel dark
•CSF study
•Lesions in brain
31

32. Flair sequence
• Fluid attenuation inversion
recovery
• Flair-ventricular ooze
• CSF black
• Pathological fluid white
32

33. T2 vs FLAIR- Flip side of T2
33

34. Identify-T1 VS T2 VS FLAIR
34

35. MR Diffusion
• Ghost sequence
• Diffusion weighted image
• DWI
• Fluid restriction
• Whiter
35

36. ADC MAP
• Apparent diffusion coefficient
• Statistical measure of restriction
• ADC measuring the diffusion
• ADC without T2 effect –black
• Hyperintense on DWI
• Hypointense in ADC
• More malignant –lower the
value
36

37. ADC values
37

38. Planning MRI
38
FOV should
include body
contour

39. Disease specific MRI sequences
DISEASE SEQUENCE
 NORMAL ANATOMY 3D FSPGR
 PITUITARY ADENOMA STIR
 TRIGEMINAL NEURALGIA FIESTA
 CRANIAL NERVES CISS
 CP ANGLE TUMOR GRE
 GLIOMA DIFFUSION,PERFUSION
 AVM ANGIO
 GRADING OF TUMORS MRS
 METASTASIS DOUBLE/TRIPLE/DELAYED CONTRAST
DIFFUSION,PERFUSION 39

40. FSPGR Sequence
• [3D FSPGR (fast spoiled gradient
echo)
• More differentiation of normal
structure
• Contrast as well as non contrast
• Improves anatomical display
40

41. 41

42. FIESTA sequence
• FIRST IMAGING EMPLOYING
STEADY STATE ACQUSITION
• Clear visualization of ventricles
• Cranial nerves AT SKULL BASE
• Cisterns
42

43. STIR sequence. Fat saturated/FATSAT sequence
• Short tau inversion recovery
• These chemically selective
pulses cause the signal
from fat to be nulled (saturated)
• Packing materials
• Gel foam
• Fat
43

44. MRS
• Magnetic resonance spectroscopy
• Chemical measurement
• Grading differentiating the tumours
44

45. Chemical composition of brain-MRS
45

46. MRS-low grade vs high grade
46

47. MRS- Meningioma
47

48. MR Angio
• Magnetic resonance angiography is
used to generate images of arteries in
order to evaluate them for stenosis,
occlusions, aneurysms or other
abnormalities
48

49. MR perfusion
1. Sequence to see perfusion of
tissues
2. The acquired data are then post-
processed to obtain perfusion maps
with different parameters, such as
BV (blood volume), BF (blood flow)
3. The main role of perfusion imaging
is in evaluation of ischemic
conditions and neoplasms (e.g.
identify highest grade component
of diffuse astrocytoma help to
distinguish glioblastomas from
cerebral metastases) and
neurodegenerative diseases.
49

50. Gradient echo sequence
• Gradient recalled echo (GRE) (T2
WI) is a relatively new (MRI)
technique.
• GRE T2 WI can detect the
smallest changes in uniformity
in the magnetic field and can
improve the rate of small lesion
detection
• Detection and Evaluation of
Microbleeds
50

51. MRI spine and sequences
51

52. 52

53. 53

54. 54
Clock wise

55. 55

56. 56

57. 57

58. 58

59. Spine sequences
• T1
• T2
• STIR
• T1C
• DIXON
• DWI
• SWI
59

60. MRI sequences
Basic sequences
1. T1
2. T2
3. Inversion recovery (IR)
4. Post contrast T1
Advanced sequences
1. DWI (Functional sequence)
2. SWI
3. Multi-point Dixon
4. Dynamic Post contrast T1
Thanks to Dr C Seetharaman 60

61. 61

62. T1W
1. Morphology of bones and soft tissue
2. Most pathological lesions appear
hypo intense against
normal fatty marrow
Thanks to Dr C Seetharaman 62

63. T1C
1. Gives details about
cellularity and necrosis
2. Dynamic post contrast
will assess vascularity
of bone metastasis
(EGFR status)
3. Response assessment
Thanks to Dr C Seetharaman 63

64. T2W
1. Adds information about morphology of
bones and soft tissue.
2. Most pathological lesions appear
hyper intenseagainst
normal marrow
Thanks to Dr C Seetharaman 64

65. IR sequence
1. Fat suppressed T2W sequence
2. More clear
3. Differentiate from T2 by back FAT[arrow]
1. Bright on T2
2. Darker on IR
4. Most pathological lesions appear
more hyper intenseagainst normal
marrow
Thanks to Dr C Seetharaman 65
T2 SEQUENCE IR SEQUENCE

66. 66

67. Susceptibility-weighted MRI spine
67
Susceptibility-weighted MRI enables the reliable differentiation between predominantly osteoblastic and
osteolytic spine metastases with a higher accuracy than standard MRI sequences

68. 68

69. THE VENTRICLES

70. Ventricles
• Lateral ventricle
• Frontal horn
• Occipital horn
• Temporal horn
• Third ventricle
• Fourth ventricle
• Central canal
Foramen monoro
Aqueduct of Silvius

72. Interventricular foramina
(or foramina of monro)

75. The lateral ventricle

76. The frontal horn

77. The
occipital
horn

78. The temporal horn

81. The 3rd ventricle

82. The 4th ventricle

84. Foramen Luschka and Magendie

85. GREY VS WHITE

86. • The CNS has two kinds of tissue: grey matter and white matter.
• Grey matter contains most of the brain's neuronal cell bodies.[outside]
• White matter is made of axons connecting different parts of grey matter to
each other[inside]

89. CordBrain

90. White and grey mater on CT

91. White and grey mater on MRI
T1 T2

93. Gray-white junction- the brain met

94. Stroke Tumor

95. Grey and white mater cord/T2

96. THE MENINGES

104. 1. Using spin-echo sequences
2. The dura mater may be recognized as a short,
intermittent, thin, hyperintense, curvilinear structure on
contrast-enhanced T1-weighted MRI.
3. The pia mater and the arachnoid mater do NOT enhance
in normal subjects

111. SULCI & GYRI

112. SULCUS IS THE DEPRESSION [VALLEYS]
AND
GYRUS IS THE RIDGE [HILLS]

115. Fissure/sulcus Importance
• Interhemispheric fissure • Separates two lobes
 Sylvian fissure/ Lateral
Sulcus
 Frontal to temporal
 Central sulcus  Frontal to parietal
 Callosal sulcus
 Cingulate sulcus
 Interparietal sulcus
 Parieto occipital sulcus
 Calcarine sulcus

116. 12
6
Interhemispheric
fissure
1
3
2
4
5
Superior frontal
sulcus
Pre central sulcus
Central sulcus
Post central
sulcus
IPIO
sulcus

118. Interhemispheric fissure

119. The central sulcus-The sigmoid hook

120. The pars bracket sign- Parieto occipital sulcus

122. Fish tail- parieto occipital sulcus

123. Pars marginalis

127. The bifid sulcus

128. The intraparietal sulcus

141. THE FISSURES

144. LOBES

155. TEMPORAL LOBE CONTOURING Francis Ho, MEDICEINE,2018

156. Normal calcification

161. The basal ganglia

165. Pituitary fossa

171. The pineal gland

173. PINEAL GLAND

174. The limbic system

176. Yellow: cingulate gyrus; red: hippocampus; green: temporal lobe
neocortex; blue: insula, pink: uncus; P: parahippocampal gyrus

177. Cisterns of brain
The subarachnoid cisterns, or basal cisterns, are compartments
within the subarachnoid space where the pia mater and
arachnoid membrane are not in close approximation and
cerebrospinal fluid (CSF) forms pools or cisterns (Latin: "box").

179. Pre pontine cisterns

180. Suprasellar cistern

183. CEREBELLUM

184. TONSIL
CEREBELLAR
HEMISPHERE

185. TONSIL
CEREBELLAR
HEMISPHERE

186. VERMIS

187. MIDDLE CEREBELLAR PEDUNCLE

188. SUPERI0R CEREBELLAR PEDUNCLE -MIDBRAIN LEVEL
HORRIZONTAL FISSURE

189. SUPERIOR CEREBELLAR PEDUNCLE -MIDBRAIN LEVEL

190. MIDDLE CEREBELLAR PEDUNCLE AT PONS

191. Brainstem = Midbrain + Pons + Medulla

195. Blood supply

200. To quickly remember the tributaries to the confluence
of sinuses you can use the mnemonic
"TOSS"
(Transverse sinus, Occipital sinus, Superior sagittal sinus,
Straight sinus
Dural sinuses

205. FUNCTIONS OF LOBES

206. Symptoms of brain tumor
• Irritative symptom
• Compressive symptom
• Obstructive symptom
• Functional symptom

208. Eloquent areas
A. Eloquent cortex is a name used by neurologists for
areas of cortex that—if removed—will result in loss
of sensory processing or linguistic ability, or paralysis.
B. The most common areas of eloquent cortex are in the
A. Left temporal and
B. Frontal lobes for speech and language,
C. Bilateral occipital lobes for vision,
D. Bilateral parietal lobes for sensation, and
E. Bilateral motor cortex for movement