beyond blood can be very bad: brain imaging...
TRANSCRIPT
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Ben Huang MD MPHUniversity of North Carolina School of Medicine
Department of Radiology
Beyond Blood Can Be Very Bad: Brain Imaging 2018
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➢ Current neuroimaging modalities
➢ Brain anatomy
➢ How to approach a head CT
➢ Wrap up
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➢ Computed tomography (CT)
➢ Magnetic resonance (MR)DWI ‒ SWIDSC PWI ‒ DTI1H MRS ‒ DCEfMRI
➢ Ultrasound
➢ Angiography to include noninvasive
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Pros
▪ Fast
▪ Excellent screening tool
▪ Clinician comfort Cons
▪ Poorer soft tissue contrast
▪ Ionizing radiation
▪ Acute contrast nephropathy
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Pros
▪ Better soft tissue contrast
▪ Multiplanar acquisition
▪ Gives more information
▪ No ionizing radiation
Cons
▪ Takes a long time
▪ ↑ susceptibility to motion
▪ More difficult to interpret
▪ Certain implants/FB contraindicated
▪ NSF
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T1-weighted
T1-weighted + Gd
T2-weighted
FLAIR
Diffusion Weighted
Diffusion Weighted (ADC)
MRI Sequences
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➢ Current neuroimaging modalities
➢ Brain anatomy
➢ How to approach a head CT
➢ Wrap up
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SMG AngGPreCS
PostCSCS
SF
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Superior frontal gyrus
Middle frontal gyrus
Precentral gyrus(Frontal lobe)
Central sulcus
Postcentral gyrus(Parietal lobe)
Precentral sulcus
Superior frontal sulcus
Postcentral sulcus
Pars marginalis Falx cerebri
Vertex to Tonsils:CT Anatomy
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Central sulcus
Centrum semiovale
Precentral sulcus
Postcentral sulcus
Precentral gyrus(Frontal lobe)
Intraparietal sulcus
Superior frontal gyrus
Middle frontal gyrus
Parieto-occipital fissure
Postcentral gyrus(Parietal lobe)
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Lateral (Sylvian) fissure, posterior segment
Caudate body
Central sulcus
Corona radiata
Lateral ventricle
Superior temporal gyrus
Parieto-occipital fissure
Intra-occipital sulcus
Superior temporal sulcus
Superior sagittal sinus
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Lateral (Sylvian) fissure
Thalamus
Internal capsule, posterior limb
3rd ventricle
Basal ganglia, lentiform nuclei (GP & putamen)
Caudate, head
Lateral ventricle, occipital horn
Lateral ventricle, frontal horn
Internal capsule, anterior limb
Insula
Parieto-occipital fissure
Calcarine sulcus
Superior temporal sulcus
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Lateral (Sylvian) fissure
Quadrigeminalcistern
MidbrainCerebral aqueduct (of Sylvius)
Superior temporal gyrus
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Olfactory sulcus
Gyrus rectus
Suprasellar cistern
Amygdala
Hippocampus
Cerebellum
Interpeduncular cistern
Ambient cistern
Cerebral peduncle
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Sella turcica
Prepontine cistern
Temporal lobe
Pons
4th ventricle
Vermis
Middle cerebellar peduncle (Brachium pontis)
Cerebellar hemisphere
Cerebellopontine angle cistern
Sigmoid sinus
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Mandibular condyle
Medulla
Cerebellar tonsil
Mastoids
Nasopharynx
Foramen magnum
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ThalamusInternal capsule, posterior limb
Basal ganglia, lentiform nuclei (GP & putamen)
Caudate, head
Internal capsule, anterior limb
Deeper Dive intoCT & MR Anatomy
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PGP
C
Th
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Ascending/Descending▪ Coronal radiata
▪ Internal capsule
Association - link different cortical areas in different lobes of same hemisphere▪ SLF − Fronto-occipital fasciculus
▪ Arcuate fasciculus − Uncinate fasciculus
▪ Extreme capsule − Cingulum
Commissural - crossing fibers linking areas in different hemispheres▪ Corpus callosum − Hippocampal commissure
▪ Anterior commissure − Habenular commissure
▪ Posterior commissure
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Centrum semiovale Corona radiata Internal capsule
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ACPC
PinealOC
Pit MB
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Associated with memory and emotional, fight/flight & sexual responses
Consists of:▪ Amygdala
▪ Hippocampus
▪ Parahippocampalgyrus
▪ Cingulate gyrus
▪ Subcallosal Gyri
Uncus
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Associated with memory and emotional, fight/flight & sexual responses
Consists of:▪ Amygdala
▪ Hippocampus
▪ Parahippocampalgyrus
▪ Cingulate gyrus
▪ Subcallosal Gyri
Uncus
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1 = Optic chiasm2 = Pituitary infundibulum (stalk)3 = Tuber cinereum4= Mammillary body
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Network of ependymal lined CSF filled spaces
▪ Derivative of neural tube cavity
4 ventricles:
▪ Paired lateral ventricles
▪ 3rd ventricle
▪ 4th ventricle
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Body, lateral ventricle
Frontal horn, lateral ventricle
Occipital horn, lateral ventricle
3rd ventricle
Foramen of Monro
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3rd ventricle
4th ventricle
Cerebral aqueduct(of Sylvius)
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Sylvian Fissure
Ambient Cistern
Quadrigeminal Plate Cistern
Interpeduncular Cistern
SuprasellarCistern
CP AngleCistern
Prepontine Cistern
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Cerebellum
▪ Paired hemispheres joined by midline vermis
▪ Coordination & muscle tone
Brainstem
▪ Midbrain, pons, medulla
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Cerebellum
▪ Paired hemispheres joined by midline vermis
▪ Coordination & muscle tone
Brainstem
▪ Midbrain, pons, medulla
MCP
BrainstemMidbrain Pons Medulla
Cerebral Peduncle
Substantia Nigra
Cerebral Aqueduct
Red Nucleus
MCPICP
4th VentricleICP
Olive
Pyramid
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C1 – Cervical C5 – ClinoidC2 – Petrous C6 – OpthalmicC3 – Lacerum C7 – Communicating (Terminal)C4 - Cavernous
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C1 – Cervical C5 – ClinoidC2 – Petrous C6 – OpthalmicC3 – Lacerum C7 – Communicating (Terminal)C4 - Cavernous
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➢ Current neuroimaging modalities
➢ Brain anatomy
➢ How to approach a head CT
➢ Wrap up
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➢ Blood (intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!*
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
*Dr Andy Perron
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➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Hypertensive intraaxialhemorrhage
Posttraumatic extraaxialhemorrhage - epidural
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Epidural Hemorrhage Epidural hemorrhage forms between inner table of calvarium and outer layer of the dura, results from middle meningeal arterial tear.
>90% are assoc with skull fx usutemporoparietal bones, also frontal and parieto-occipital regions.
On CT: hyperdense biconvex lens shape, mass effect. Early identification critical to guide evacuation vs early reevaluation
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Epidural Hemorrhage Epidural hemorrhage forms between inner table of calvarium and outer layer of the dura, results from middle meningeal arterial tear.
>90% are assoc with skull fx usutemporoparietal bones, also frontal and parieto-occipital regions.
On CT: hyperdense biconvex lens shape, mass effect. Early identification critical to guide evacuation vs early reevaluation
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➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Stroke CT windowing W 30 L 30 –note left parietal lobe loss of gray-
white matter differentiation compared to right
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➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Stroke CT windowing W 30 L 30 –note left parietal lobe loss of gray-
white matter differentiation compared to right
Complete loss of gray-white matter differentiation bilateral
hemispheres
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➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Stroke CT windowing W 30 L 30 –note left parietal lobe loss of gray-
white matter differentiation compared to right
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➢ Is there midline shift?➢ Is brain symmetry preserved?➢ Are the cisterns patent
(smile and pentagon)?➢ Is the 4th ventricle patent
and symmetric?➢ Are the ventricles enlarged
with sulcal effacement?
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
+midline shift+hemispheric asymmetry
+cistern effacement+lateral ventriculomegaly and
sulcal effacement
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Subdural Hemorrhage Subdural hemorrhage (SDH) collects in the potential space between the inner dura and the arachnoid layer
Result from bridging vein tear in a MVA or fall
On CT: hyperdense crescentic shape when acute, then isodense to hypodense when subacute and chronic. Mass effect -> altered mental status
![Page 48: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/48.jpg)
+SDHCT Checklist:
+ Midline shift
+ Loss of symmetry
+ Cisternal effacementSubfalcine and uncalherniation
Needs NSU !
![Page 49: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/49.jpg)
➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Stroke CT windowing W 30 L 30 –note left parietal lobe loss of gray-
white matter differentiation compared to right
![Page 50: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/50.jpg)
➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Note bilateral lateral ventriculomegaly. Distinguish
hydrocephalus from atrophy via diffuse sulci prominence
![Page 51: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/51.jpg)
➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
BonesDepressed skull fx left parietooccipital bone from
penetrating trauma
![Page 52: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/52.jpg)
➢ Blood (Intra- vs extraaxial)➢ Gray/white differentiation➢ Edema➢ Masses/Mass effect (midline shift, cistern
effacement, herniation ➢ Ventricles (hydrocephalus)➢ Bones (fx, lysis, sclerosis)➢ Paranasal sinuses and mastoids➢ Extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
Expansile soft tissue massleft frontal sinus
![Page 53: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/53.jpg)
➢ Blood - intra- and extraaxial➢ Cisterns and extraaxial CSF - effacement or
asymmetry➢ Brain parenchyma - gray/white differentiation
symmetry, shift, hyper- hypodensity➢ Ventricles - too large or too small➢ Bones - skull fx, paranasal sinuses, mastoids
and extracranial soft tissues
Blood Can Be
Very Bad!
~~~~~~~~~~~~
Blood
Cisterns
Brain
Ventricles
Bones
![Page 54: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/54.jpg)
➢ CT vs MRICT is a great screening tool
MR is good for problem solving & assessing established pathology
➢ Brain anatomy
➢ How to approach a head CTBlood Can Be Very Bad
➢ Emergency checklist Shift, cisternal effacement, or hydrocephalus
![Page 55: Beyond Blood Can Be Very Bad: Brain Imaging 2018msrads.web.unc.edu/files/2018/04/Brain-Imaging-2018-1.pdf · 2018. 4. 17. · Blood (Intra- vs extraaxial) Gray/white differentiation](https://reader036.vdocuments.mx/reader036/viewer/2022063009/5fc1b31c17b1a82e192ae463/html5/thumbnails/55.jpg)
Thank you for participating!
http://guides.lib.unc.edu/radiology/booksNeuroradiology references