technique of imaging of brain space occupying lesions

1. C.N.SC.N.S..Space occupying lesionSpace occupying lesion

2. Dr.Mohamed Ashraf Zaitoun, MD
Interventional Radiology Consultant, Zagazig University
Hospitals, Egypt
FINR-Switzerland
zaitoun82@gmail.com
www.zaitounclinic.com

3. DedicationDedication
To the memory of my late father, Prof Ashraf ZaitounTo the memory of my late father, Prof Ashraf Zaitoun
Interventional
Radiology Unit,
Zagazig University,
Egypt

4. Space occupying lesionSpace occupying lesion
11--Plain x-raysPlain x-rays
22--CTCT
33--MRIMRI
44--Carotid angioCarotid angio
55--USUS
66--ThermographyThermography
77--CysternographyCysternography
88--Isotope scanningIsotope scanning
99--MRAMRA
1010--Diffusion & perfusion MRIDiffusion & perfusion MRI
1111--MRSMRS
1212--PET CTPET CT

5. Space occupying lesionSpace occupying lesion
11--Plain x-raysPlain x-rays
--See positionsSee positions
--IndicationsIndications::
F.BF.B..
FracturesFractures
SinusitisSinusitis

6. 11--Pituitary fossa 2-Ant. Clinoid process 3-Post clinoidPituitary fossa 2-Ant. Clinoid process 3-Post clinoid
44--Sphenoid air sinus 5-Petrous temporal boneSphenoid air sinus 5-Petrous temporal bone

7. Space occupying lesionSpace occupying lesion
22--CT brainCT brain
IndicationsIndications
CICI
Patient preparationPatient preparation
CMCM
TechniqueTechnique
ComplicationsComplications
Interpretation ( AnatomyInterpretation ( Anatomy((

8. Space occupying lesionSpace occupying lesion
**Indications: technique & CMIndications: technique & CM
--TechniqueTechnique<<<<
Best indications are in emergencies otherwise MRI is betterBest indications are in emergencies otherwise MRI is better<<<<<<
11--Congenital diseases ( e.g. hydrocephalusCongenital diseases ( e.g. hydrocephalus((
22--TraumaticTraumatic
33--Infections ( use CMInfections ( use CM((
44--Neoplasms ( MRI is betterNeoplasms ( MRI is better((
55--OthersOthers::
Suspected ICHSuspected ICH
Suspected increase in ICTSuspected increase in ICT
StrokeStroke
SeizuresSeizures
headacheheadache

9. Space occupying lesionSpace occupying lesion
--Contrast mediaContrast media::
11--SeizuresSeizures
22--HeadacheHeadache
33--Suspected increase in ICTSuspected increase in ICT
44--Suspected tumorSuspected tumor
55--Vascular malformationVascular malformation
66--Focal lesion appears in NECTFocal lesion appears in NECT

10. Space occupying lesionSpace occupying lesion
--C.IC.I. :. :
11--Radiation (pregnancy in 1Radiation (pregnancy in 1stst
trimestertrimester((
22--Of contrast mediaOf contrast media<<<<
Sepsis at injection siteSepsis at injection site
TraumaTrauma
StrokeStroke
Renal failure ( always ask patient for CRRenal failure ( always ask patient for CR((
Allergy to CMAllergy to CM

11. Space occupying lesionSpace occupying lesion
**Patient preparationPatient preparation::
--Fasting before CM injectionFasting before CM injection<<<<
44hrs in childrenhrs in children
66hrs in adultshrs in adults
As reaction may cause vomiting & aspirationAs reaction may cause vomiting & aspiration
--SedationSedation<<<<
In children & non co-operative ptsIn children & non co-operative pts

12. Space occupying lesionSpace occupying lesion
**CMCM::
Urographin ( 20 ml ampuleUrographin ( 20 ml ampule((
22or 3 ampulesor 3 ampules

13. Space occupying lesionSpace occupying lesion
**TechniqueTechnique::
PositionPosition
DataData
ScanogramScanogram
CutsCuts
WindowWindow

14. Space occupying lesionSpace occupying lesion
--PositionPosition::
Supine in most casesSupine in most cases
Well centralized & stableWell centralized & stable
--DataData::
Data of the pt should be fed into the computerData of the pt should be fed into the computer
before startingbefore starting

15. Space occupying lesionSpace occupying lesion
--ScanogramScanogram::
Lateral viewLateral view
--CutsCuts::
****BaselineBaseline<<<<
Orbito-meatal lineOrbito-meatal line
))between lat. Canthus & EAMbetween lat. Canthus & EAM((

17. Space occupying lesionSpace occupying lesion
****Axial cutsAxial cuts::
1010mm intervalsmm intervals
55mm in post. Fossamm in post. Fossa
66mm in childrenmm in children

18. Space occupying lesionSpace occupying lesion
**WindowWindow::
Soft tissue windowSoft tissue window
Bone window ( if there is history of traumaBone window ( if there is history of trauma((
**ComplicationsComplications::
--Of contrast media (hotness , mouth bitterness ,Of contrast media (hotness , mouth bitterness ,
sneezing , cyanosis , laryngeal edemasneezing , cyanosis , laryngeal edema((
--Of sedationOf sedation

19. Space occupying lesionSpace occupying lesion
**Interpretation ( AnatomyInterpretation ( Anatomy((
--Below level of lateral ventricleBelow level of lateral ventricle
--At level of lateral ventricleAt level of lateral ventricle
--Above level of lateral ventricleAbove level of lateral ventricle

20. Space occupying lesionSpace occupying lesion
****Below level of lat. VentricleBelow level of lat. Ventricle::
--Anatomical landmark is 4Anatomical landmark is 4thth
ventricleventricle
--Discuss 4Discuss 4thth
ventricle relationsventricle relations
--Cuts above 4Cuts above 4thth
ventricle >> discuss CT of cisternsventricle >> discuss CT of cisterns

21. CT Axial section above foramenCT Axial section above foramen
magnummagnum
Frontal sinus
Sphenoid sinus
Temporal lobe
Basilar A.
Mastoid cells
Cerebellar
hemisphere
Cisterna magna
Medulla
Optic nerve
Pituitary
Sphenoid bone
Temporal bone
Cerebellar tonsils

22. CT Axial section at 4CT Axial section at 4thth
ventricleventricle
Frontal sinus
Frontal bone
Mid.cerebral A
Basilar A.
Pons
4th
vent
cerebellum
Mid cerebellar
peduncle
Petrous bone
Temporal horn
Ant.cerebral a
Sella turcica
Vermis

23. CECT Axial sectionCECT Axial section aboveabove 44thth
ventricleventricle
Frontal lobe
Ant cerebral A.
4TH
vent
Cerebellum
Pons
Temporal horn
Infundibulum
Post.cerebral A.
Sphenoid bone
Frontal bone
Frontal sinus
Mid.cerebral A

24. Space occupying lesionSpace occupying lesion
****At level of lat. VentricleAt level of lat. Ventricle::
<<level of BGlevel of BG
a)lat. Ventriclea)lat. Ventricle
b)3b)3rdrd
ventricle in midlineventricle in midline
c)BG : caudate > mediallyc)BG : caudate > medially
lentiform > laterallylentiform > laterally
ant. Limb of internal capsuleant. Limb of internal capsule
in betweenin between
d)Thalamus: on either side of 3d)Thalamus: on either side of 3rdrd
ventricle with post. Limb ofventricle with post. Limb of
internal capsule in between it & lentiforminternal capsule in between it & lentiform
e)Sylvian fissure & the insula : external capsule between & lentiforme)Sylvian fissure & the insula : external capsule between & lentiform

25. CT Axial section at 3CT Axial section at 3rdrd
ventricleventricle
Genu of corpus
callosum
Caudate nucleus
Int.capsule
3rd
ventricle
Pineal gland
vermisOccipital lobe
Choroid plexus
Thalamus
Lentiform nucleus
Frontal horn
Pericallosal A

26. Space occupying lesionSpace occupying lesion
****At level of bodyAt level of body::
Body of caudate Septum pellucidumBody of caudate Septum pellucidum
****Above level of lateral ventricleAbove level of lateral ventricle::
Two cerebral hemispheres & the falx cerebri inTwo cerebral hemispheres & the falx cerebri in
betweenbetween

27. CT Axial section at mid ventriclesCT Axial section at mid ventricles
Cingulate gyrus
Body of
lateral
ventricle
Corpus callosum
Falx
cerebri
Occipital horns
Parietal lobe
Corona radiata
Frontal horns
Confluence of
Sinuses (torcula)

28. CT Axial section at centrum semiovaleCT Axial section at centrum semiovale
Falx cerebri
Centrum
semiovale
Occipital lobe
Parietal lobe
Frontal lobe

29. CT Axial sections(bone windowCT Axial sections(bone window((
Ear ossicles
Mastoid air cellscochlea
Int. acoustic
meatus
Aditus to antrum
Sq.temporal
bone Facial n canal
Ethmoidal sinus

30. CT Axial sections(bone windowCT Axial sections(bone window((
Occipital bone
Jugular foramen
Base sphenoid
Sphenoid sinus
Ext.acoustic C
Mastoid air cells
Carotid canal
Greater wing of
sphenoid

31. Space occupying lesionSpace occupying lesion
33--MRIMRI
IndicationsIndications
CICI
Patient preparationPatient preparation
CMCM
TechniqueTechnique
ComplicationsComplications
InterpretationInterpretation
AdvantagesAdvantages
DisadvantagesDisadvantages

32. Space occupying lesionSpace occupying lesion
**IndicationsIndications::
--Diagnosis of diseases canDiagnosis of diseases can’’t be adequatelyt be adequately
diagnosed by CT >> Epilepsy MSdiagnosed by CT >> Epilepsy MS
--To detect pathology in areas which CT isnotTo detect pathology in areas which CT isnot
helpful >> posterior fossahelpful >> posterior fossa
--Confirm CT diagnosis as it gives better viewConfirm CT diagnosis as it gives better view

33. Space occupying lesionSpace occupying lesion
**CICI::
--To MRI >> see physicsTo MRI >> see physics
--To CM >> see physicsTo CM >> see physics

34. Space occupying lesionSpace occupying lesion
**Patient preparationPatient preparation::
--Fasting as in CTFasting as in CT
--Sedation or anaesthesiaSedation or anaesthesia<<<<
ClaustrophobiaClaustrophobia
ChildrenChildren
Neurological conditions (epilepsy &Neurological conditions (epilepsy &
parkinsonismparkinsonism((

35. Space occupying lesionSpace occupying lesion
**CMCM::
See contrast mediaSee contrast media

36. Space occupying lesionSpace occupying lesion
**TechniqueTechnique::
--Patient is supinePatient is supine
--Patient data + patient weightPatient data + patient weight
--ProtocolProtocol<<<<
****No angle is used ( so part of the occipital lobeNo angle is used ( so part of the occipital lobe
appears behind the cerebellumappears behind the cerebellum((
****Cut thickness is 5 mm and cuts interval is 2 mmCut thickness is 5 mm and cuts interval is 2 mm

37. Space occupying lesionSpace occupying lesion
****FilmsFilms::
Axial T1 , T2 & FLAIR ( or PDAxial T1 , T2 & FLAIR ( or PD((
Sagittal T1Sagittal T1
Coronal T2Coronal T2
--Post contrast filmsPost contrast films<<<<
T1 ( axial , sagittal & CoronalT1 ( axial , sagittal & Coronal((
--Sagittal filmsSagittal films<<<<
Corpus callosumCorpus callosum
Cranio-cervical junctionCranio-cervical junction
SSSSSS
--Coronal filmsCoronal films<<<<
Pituitary glandPituitary gland
HippocamousHippocamous
Skull baseSkull base
Posterior fossaPosterior fossa

38. Space occupying lesionSpace occupying lesion
**ComplicationsComplications::
As in CTAs in CT

39. Space occupying lesionSpace occupying lesion
**InterpretationInterpretation::
--Anatomy >> as in CTAnatomy >> as in CT
--Identify the sequences >>Identify the sequences >>
T1 , T2 & FLAIRT1 , T2 & FLAIR
TRTR TETE CSFCSF
T1T1 <<800800`` 2020 DarkDark
T2T2 <<100100
00
8080 BrightBright
PDPD <<100100
00
2020 GrayGray

40. MRI Axial section above foramenMRI Axial section above foramen
magnummagnum
Maxillary
sinus
Basilar A.
Medulla
Cerebellar
hemisphere
Cisterna magna
Tonsils
Petrous bone
Sphenoid sinus
Nasal cavity
Zygomatic arch

41. MRI Axial Section at 4MRI Axial Section at 4thth
VentricleVentricle
Lens
Optic nerve
Pituitary
Temporal lobe
Middle
cerebellar
peduncle
4th
Ventricle
Medial rectus
Lateral rectus
Pons
Petrous
temporal
bone
Cerebellar
hemisphere

42. MRI Axial Section above 4MRI Axial Section above 4thth
ventricleventricle
Superior
oblique muscle
Pituitary stalk
Upper pons
Superior
cerebellar
peduncle
Optic chiasma
Ambient cistern
Cerebellar folia

43. MRI Axial section at midbrainMRI Axial section at midbrain
Frontal lobe
Interpeduncula
r
cisterni
n
f
e
r
i
Vermis
Inferior colliculi
Confluence of
sinuses
Ambient cistern
Uncus
Optic tract
Mid cerebralA
Cerebral
peduncle
Ant cerebral A

44. MRI Axial section at 3MRI Axial section at 3rdrd
ventricleventricle
Genu of corpus
callosum
Caudate head
Lentiform nuleus
Thalamus
Splenium of
corpus callosum
Frontal horns
Int.capsule
Insula
3rd
ventricle
Occipital horns
Optic radiation

45. MRI Axial section at mid ventricleMRI Axial section at mid ventricle
Cingulate gyrus
Body of lateral
ventricle
Corpus callosum
Central sulcus
Corpus callosum
Inter hemispheric
fissure

46. MRI Axial section at centrumMRI Axial section at centrum
semiovalesemiovale
Inter hemispheric
fissure
Centrum semiovale
Occipital lobe
Parietal lobe
Frontal lobe

47. MRI Coronal section at 3MRI Coronal section at 3rdrd
ventricleventricle
Frontal horns
Fornix
3rd
ventricle
Clivus
Interpeduncular
cistern
Insula
Sylvian fissure
Temporal lobe
Parotid
gland
Odontoid (dens)

48. MRI Coronal section at suprasellarMRI Coronal section at suprasellar
levellevel
Inter hemispheric
fissure
Lat ventricle
Lat.Pterygoid Ms
Nasopharynx
Med.Pterygoid
Ms
.
Sylvian fissure
Sphenoid sinus
Pituitary gland Optic chiasm
Ant cerebral a
Mid cerebral
A

49. MRI Coronal section at post. ventricleMRI Coronal section at post. ventricle
Parietal lobe
Splenium of corpus
callosum
Sup.cerebellar
cistern
Tentorium
Choroid plexus
Atria of
lateral
ventricle
4th
ventricle

50. MRI Sagittal sectionMRI Sagittal section
Lat vent
Genu
3rd
vent
Sphenoid
sinus
Nasopharynx
Body of CC
Splenium
Quadrigemina
cistern
Pons
4th
vent
Medulla
Cerebellum
Tonsil
Cingulate gyrus
Prepontine cistern

51. Space occupying lesionSpace occupying lesion
T1 : gray matter >> grayT1 : gray matter >> gray
white matter >> brightwhite matter >> bright
T2 : gray matter >> grayT2 : gray matter >> gray
white matter >> darkwhite matter >> dark
FLAIR : as T2 but CSF is black ( signal voidFLAIR : as T2 but CSF is black ( signal void((

52. Space occupying lesionSpace occupying lesion
--Assess signal intensity of structures & lesions inAssess signal intensity of structures & lesions in
T1 , T2 & FLAIRT1 , T2 & FLAIR::
**High T1 & T2 >> subacute blood (met HbHigh T1 & T2 >> subacute blood (met Hb((
**Low T1 & T2Low T1 & T2<<<<
a) No flowing mobile protonsa) No flowing mobile protons
Coritcal bones ( petrous) , calcification , matureCoritcal bones ( petrous) , calcification , mature
fibrous tissue ( tendons & ligamentsfibrous tissue ( tendons & ligaments((

53. Space occupying lesionSpace occupying lesion
b) Flowing blood = Signal voidb) Flowing blood = Signal void
Aqueduct of sylviusAqueduct of sylvius
c) Air ( minimal H2 protonsc) Air ( minimal H2 protons((
d) Hemosiderin ( chronic hematomad) Hemosiderin ( chronic hematoma((
**High T1 & low T2High T1 & low T2::
Fat & fat containing structures ( cholesterol ,Fat & fat containing structures ( cholesterol ,
dermoid cystdermoid cyst
N.B. >> fat in T2 is gray not darkN.B. >> fat in T2 is gray not dark

54. Space occupying lesionSpace occupying lesion
**Low T1 & high T2Low T1 & high T2::
a) Fluids ( CSF , ascitis , urinea) Fluids ( CSF , ascitis , urine((
b) Edemab) Edema
c) Most of brain tumorsc) Most of brain tumors
d) Infarctiond) Infarction

55. Space occupying lesionSpace occupying lesion
**Advantages over CTAdvantages over CT::
11--MPI ( Axial , sagittal & coronalMPI ( Axial , sagittal & coronal((
22--Sensitive ( especially psoterior fossaSensitive ( especially psoterior fossa((
33--No ionizing radiationNo ionizing radiation
44--AVM diagnosis ( without the need for CMAVM diagnosis ( without the need for CM((
55--Tissue characterizationTissue characterization

56. Space occupying lesionSpace occupying lesion
**DisadvantagesDisadvantages::
a) High costa) High cost
b) Less avaialbilityb) Less avaialbility
c) Has absolute CIc) Has absolute CI

57. Space occupying lesionSpace occupying lesion
44--Cerebral angiographyCerebral angiography::
See carotid angiographySee carotid angiography
55--USUS::
--In neonates >> through ant. FontanelleIn neonates >> through ant. Fontanelle
To assess the brain & ventricular systemTo assess the brain & ventricular system
))HydrocephalusHydrocephalus((
--Also through craniotomy in adultsAlso through craniotomy in adults
--Doppler >> to detect blood flow in suspected carotidDoppler >> to detect blood flow in suspected carotid
lesionlesion..

58. Space occupying lesionSpace occupying lesion
66--CisternographyCisternography::
Contrast study of subarachnoid cysternContrast study of subarachnoid cystern
Used in small masses in CP angleUsed in small masses in CP angle
77--ThermographyThermography::
--Graphic record forGraphic record for<<<<
Infrared radiation from the skin which indirectly reflectsInfrared radiation from the skin which indirectly reflects
the continuous blood supplythe continuous blood supply
--In carotid occlusion >> decrease the flow & andIn carotid occlusion >> decrease the flow & and
decrease heat emission from the foreheaddecrease heat emission from the forehead

59. Space occupying lesionSpace occupying lesion
--UsesUses::
Brain tumorsBrain tumors
Carotid artery occlusionCarotid artery occlusion
Capral tunnel syndromeCapral tunnel syndrome
BreastBreast
88--Isotope scanningIsotope scanning::
See isotopeSee isotope

60. Space occupying lesionSpace occupying lesion
99--MRA 10- Diffusion & perfusion MRIMRA 10- Diffusion & perfusion MRI
1111--MR Spectroscopy 12- PET CTMR Spectroscopy 12- PET CT
See physicsSee physics

61. MRS ( MR spectroscopyMRS ( MR spectroscopy((
IndicationsIndications
C.IC.I..
Patient preparationPatient preparation
TechniqueTechnique
Major brain metabolitesMajor brain metabolites
After careAfter care
ComplicationsComplications

62. **IndicationsIndications::
11--Metabolic components of brain lesionsMetabolic components of brain lesions
Benign/malignant tumorsBenign/malignant tumors
Multiple sclerosisMultiple sclerosis
Cerebrovascular disease , infectionCerebrovascular disease , infection
22--Breast , prostate , spine & heartBreast , prostate , spine & heart

63. **C.I. : to MRIC.I. : to MRI
a)Absolutea)Absolute
11--Cardiac pacemakerCardiac pacemaker
22--Cliiped aneurysmCliiped aneurysm
33--Intraocular F.BIntraocular F.B..
b)Relativeb)Relative
11--Cochlear implant , insulin pump ( affect the signalCochlear implant , insulin pump ( affect the signal
qualityquality((
22--Marked obesity , claustrophobia ( open magnetMarked obesity , claustrophobia ( open magnet((

64. **Patient preparationPatient preparation::
--Sedation in claustrophobia , epilepsy , parkinsonSedation in claustrophobia , epilepsy , parkinson’’s diseases disease
& children& children
**TechniqueTechnique::
MRS can be performed by two methodsMRS can be performed by two methods::
11--Single-voxel spectroscopy (SVS), where a single sampleSingle-voxel spectroscopy (SVS), where a single sample
volume is selected and a spectrum obtained fromvolume is selected and a spectrum obtained from
22--Multi-voxel spectroscopy where spectra are obtainedMulti-voxel spectroscopy where spectra are obtained
from multiple voxels in a single slab of tissuefrom multiple voxels in a single slab of tissue

65. **Major Metabolites in the BrainMajor Metabolites in the Brain::
NAANAA
CholineCholine
CreatineCreatine
LactateLactate
GlutamineGlutamine
LipidLipid
Myo-InositolMyo-Inositol

66. The 1H-MRS spectrum of major metabolites in a normalThe 1H-MRS spectrum of major metabolites in a normal
brain is shownbrain is shown

67. N-ACETYLASPARTATE (NAAN-ACETYLASPARTATE (NAA((
--NAA is the marker of neuronal density andNAA is the marker of neuronal density and
viabilityviability..
--It is present in both gray and white matter andIt is present in both gray and white matter and
the difference in concentration is not clinicallythe difference in concentration is not clinically
significantsignificant..
--Its concentration appears to decrease with anyIts concentration appears to decrease with any
brain insults such as infection, ischemic injury,brain insults such as infection, ischemic injury,
neoplasm, and demyelination processneoplasm, and demyelination process..
NAA is not in found in tumors outside the centralNAA is not in found in tumors outside the central
nervous system (CNS) such as meningiomanervous system (CNS) such as meningioma..

69. CholineCholine
--Elevation of choline can be seen during ischemicElevation of choline can be seen during ischemic
injury, neoplasm or acute demyelinationinjury, neoplasm or acute demyelination
diseasesdiseases..
--Many brain tumors will lead to elevated cholineMany brain tumors will lead to elevated choline
peak, presumably associated with their increasedpeak, presumably associated with their increased
cellularity and compression of surrounding braincellularity and compression of surrounding brain
tissuetissue..

71. Creatine ( CrCreatine ( Cr((
--Reduced Cr level may be seen in pathologicReduced Cr level may be seen in pathologic
processes such as neoplasm, ischemic injury,processes such as neoplasm, ischemic injury,
infection or some systemic diseasesinfection or some systemic diseases..
--Most metastatic tumors to the brain do notMost metastatic tumors to the brain do not
produce creatine since they do not possessproduce creatine since they do not possess
creatine kinasecreatine kinase..
--Therefore, metastatic tumors should beTherefore, metastatic tumors should be
suspected if there is an absence of a Cr peaksuspected if there is an absence of a Cr peak
in the proton spectrumin the proton spectrum..

73. LactateLactate
--Lactate levels in the brain are normally are very low orLactate levels in the brain are normally are very low or
absent.absent. When oxygen supply is depleted, the brainWhen oxygen supply is depleted, the brain
switches to anaerobic respiration for which one endswitches to anaerobic respiration for which one end
product is lactateproduct is lactate..
--Therefore, elevated lactate peak is a sign of hypoxicTherefore, elevated lactate peak is a sign of hypoxic
tissuetissue..
--Low oxygen supply can result from decreased oxygenLow oxygen supply can result from decreased oxygen
supply or increased oxygen requirementsupply or increased oxygen requirement..
The former may be seen in vascular insults, orThe former may be seen in vascular insults, or
hypoventilation and the latter may be seen inhypoventilation and the latter may be seen in
neoplastic tissueneoplastic tissue..

75. Myo-Inositol (mIMyo-Inositol (mI((
--It is found mainly in astrocytes and helps to regulate cellIt is found mainly in astrocytes and helps to regulate cell
volumevolume..
--Elevated level of mI would be seen where there is glialElevated level of mI would be seen where there is glial
cell proliferation as in gliosiscell proliferation as in gliosis..
--Depressed level of mI would be seen processesDepressed level of mI would be seen processes
causing glial cell destruction , as in neoplasm,causing glial cell destruction , as in neoplasm,
infection or ischemic injuryinfection or ischemic injury..

77. LipidsLipids
--Lipid peak should not be seen unless there isLipid peak should not be seen unless there is
destructive process of the brain including necrosis,destructive process of the brain including necrosis,
inflammation or infectioninflammation or infection..

78. Glutamate and Glutamine (GlxGlutamate and Glutamine (Glx((
--Glutamate is an excitatory neurotransmitter inGlutamate is an excitatory neurotransmitter in
mitochondrial metabolismmitochondrial metabolism..
--Glutamine and glutamate resonate closelyGlutamine and glutamate resonate closely
togethertogether..

80. **After care & complicationsAfter care & complications : :
NoneNone

82. What is PET/CTWhat is PET/CT
--An imaging modality that allows the clinician toAn imaging modality that allows the clinician to
better differentiate benign vs malignantbetter differentiate benign vs malignant
structural abnormalities seen on CT as well asstructural abnormalities seen on CT as well as
see possible malignancies where no structuralsee possible malignancies where no structural
abnormalities are seenabnormalities are seen..

83. --Stands for positron emission tomographyStands for positron emission tomography
--Fluorine-18-deoxyglucose (FDG), a radionuclideFluorine-18-deoxyglucose (FDG), a radionuclide
labeled glucose analogue is injected and the pt islabeled glucose analogue is injected and the pt is
imagedimaged

84. IndicationsIndications
11--Breast cancer: staging of distant metastasis, restaging,Breast cancer: staging of distant metastasis, restaging,
and monitoring response to treatment (when aand monitoring response to treatment (when a
change in therapy is anticipated based on resultschange in therapy is anticipated based on results((
22--Cervical cancer: staging as adjunct to conventionalCervical cancer: staging as adjunct to conventional
imagingimaging
33--Colorectal cancer: diagnosis, staging, and restagingColorectal cancer: diagnosis, staging, and restaging
44--Esophageal cancer: diagnosis, staging, and restagingEsophageal cancer: diagnosis, staging, and restaging
55--Head and neck cancer diagnosis, staging, and restagingHead and neck cancer diagnosis, staging, and restaging
66--Lymphoma: diagnosis, staging, and restagingLymphoma: diagnosis, staging, and restaging

85. 77--Melanoma: diagnosis, staging, and restagingMelanoma: diagnosis, staging, and restaging
88--Non small cell lung cancer: diagnosis, staging, andNon small cell lung cancer: diagnosis, staging, and
restagingrestaging
99--Solitary pulmonary nodules: characterizationSolitary pulmonary nodules: characterization
1010--Follicular cell thyroid cancer: restaging of recurrent orFollicular cell thyroid cancer: restaging of recurrent or
residual disease previously treated by thyroidectomyresidual disease previously treated by thyroidectomy
1111--Myocardial viabilityMyocardial viability
1212--Refractory seizures (brain): pre-surgical evaluationRefractory seizures (brain): pre-surgical evaluation
onlyonly

86. **TechniqueTechnique : :
--Malignant cells take inherently have a higherMalignant cells take inherently have a higher
metabolism than non-malignant cells. Theymetabolism than non-malignant cells. They
have a higher mitotic rate as well as morehave a higher mitotic rate as well as more
ineffecient aerobic metabolism leading to moreineffecient aerobic metabolism leading to more
anaerobic metabolismanaerobic metabolism
--Through these mechanisms they will take up theThrough these mechanisms they will take up the
FDG at a faster rate and this will can be seen onFDG at a faster rate and this will can be seen on
the scan as the FDG decaysthe scan as the FDG decays..

87. Limitations of PET/CTLimitations of PET/CT
--FDG is not cancer specific and will accumulate inFDG is not cancer specific and will accumulate in
any areas of high rates of metabolism andany areas of high rates of metabolism and
glycolysisglycolysis. .
--Therefore, increased uptake can be expected in allTherefore, increased uptake can be expected in all
sites of hyperactivity at the time of FDGsites of hyperactivity at the time of FDG
administration (e.g. muscles and nervous systemadministration (e.g. muscles and nervous system
tissues); at sites of active inflammation ortissues); at sites of active inflammation or
infection (e.g. sarcoidosis, arthritis, infectioninfection (e.g. sarcoidosis, arthritis, infection
etc.); and at sites of active tissue repair (e.g.etc.); and at sites of active tissue repair (e.g.
surgical or traumatic wounds, healing fractures,surgical or traumatic wounds, healing fractures,
etcetc.(..(.

89. Diffusion & perfusion MRIDiffusion & perfusion MRI
**DefinitionDefinition : :
--Diffusion-weighted magnetic resonance imaging (DWI)Diffusion-weighted magnetic resonance imaging (DWI)
and perfusion-weighted magnetic resonance imagingand perfusion-weighted magnetic resonance imaging
(PWI) are two kinds of magnetic resonance imaging(PWI) are two kinds of magnetic resonance imaging
(MRI) tests. MRI uses a large magnetic field, pulses of(MRI) tests. MRI uses a large magnetic field, pulses of
radio waves, and a computer to produce detailed, cross-radio waves, and a computer to produce detailed, cross-
sectional images of internal organs and blood vesselssectional images of internal organs and blood vessels

90. **IndicationsIndications : :
11--StrokeStroke
DWI and PWI used together provide information aboutDWI and PWI used together provide information about
the location and extent of cell death within minutes ofthe location and extent of cell death within minutes of
stroke, and have been shown to be superior tostroke, and have been shown to be superior to
conventional MRIconventional MRI
22--Brain or pituitary gland tumorBrain or pituitary gland tumor
33--Pituitary diseasePituitary disease
44--Brain stem or cerebellum abnormalities; andBrain stem or cerebellum abnormalities; and
55--Multiple sclerosisMultiple sclerosis

91. **C.IC.I. :. :
Of MRIOf MRI
**Patient preparationPatient preparation : :
Sedatives for anxious patientsSedatives for anxious patients

92. **TechniqueTechnique : :
--They each create images that can show the differenceThey each create images that can show the difference
between healthy and unhealthy tissue. DWI shows thebetween healthy and unhealthy tissue. DWI shows the
diffusion (movement) of water through the brain. Andiffusion (movement) of water through the brain. An
increase in water diffusion suggests cell death; aincrease in water diffusion suggests cell death; a
decrease in diffusion could be due to swelling of cellsdecrease in diffusion could be due to swelling of cells
before they die. The test is used for early, rapidbefore they die. The test is used for early, rapid
detection of stroke. (The whole brain can be imaged indetection of stroke. (The whole brain can be imaged in
less than 1 minute.) PWI uses MR contrast to showless than 1 minute.) PWI uses MR contrast to show
blood flow through the blood vessels of the brain; itblood flow through the blood vessels of the brain; it
can show a decrease in cerebral blood flowcan show a decrease in cerebral blood flow

93. **After careAfter care : :
If patients are given contrast as part of the test,If patients are given contrast as part of the test,
they will be asked to drink liquids to flush thethey will be asked to drink liquids to flush the
dye from their body. Otherwise, patients candye from their body. Otherwise, patients can
resume normal activities immediatelyresume normal activities immediately