Laura Tormoehlen, M.D. Neurology and EM-Toxicology Indiana … · 2014. 4. 4. · Neuroimaging 101...
Transcript of Laura Tormoehlen, M.D. Neurology and EM-Toxicology Indiana … · 2014. 4. 4. · Neuroimaging 101...
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Laura Tormoehlen, M.D. Neurology and EM-Toxicology
Indiana University
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Disclosures
! No conflicts of interest to disclose
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Neuroimaging 101 ! Plain films ! Computed
tomography " Angiography " Perfusion
! Magnetic resonance imaging " Diffusion-weighted
Imaging " Spectroscopy " Functional MRI " Diffusion Tensor
Imaging
! Angiography ! Myelography ! Ultrasound ! Nuclear Medicine
" Positron Emission Tomography
" Single-photon Emission Computed Tomography
" Cerebral Blood Flow
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Neuroimaging 101 ! Plain films ! Computed
tomography " Angiography " Perfusion
! Magnetic resonance imaging " Diffusion-weighted
Imaging " Spectroscopy " Functional MRI " Diffusion Tensor
Imaging
! Angiography ! Myelography ! Ultrasound ! Nuclear Medicine
" Positron Emission Tomography
" Single-photon Emission Computed Tomography
" Cerebral Blood Flow
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Neuroimaging 101 ! Magnetic resonance
imaging " Diffusion-weighted
Imaging (DWI) " Spectroscopy (MRS)
! Nuclear Medicine " Single-photon
Emission Computed Tomography (SPECT)
" Cerebral Blood Flow (CBF)
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Introduction
! Patterns of abnormal imaging findings: " Diffuse " Focal " Multifocal
! Neurotoxic disease " Usually diffuse " Occasionally multifocal " Commonly sub-MRI
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Standard MRI
! T1 ! T2 ! FLAIR ! DWI ! ADC ! GRE
! Contrast needs to be specified
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MRI sequences ! T1 with and without contrast ! T2 ! FLAIR ! Diffusion-Weighted Imaging (DWI) ! Apparent Diffusion Coefficient (ADC) ! Gradient Echo (GRE)
! All are done in axial plane, some also done in sagittal and coronal
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How does a CT scan help? ! Screening test
" Hemorrhage " Focal lesion " Severe diffuse
disease ! Trauma/fractures ! Calcified lesions ! Temporal bone/sinus
disease
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CT versus MR ! CT- differential
attenuation of x-ray
! MR- response of tissue to magnetic field
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FLAIR imaging
! Fluid attenuated inversion recovery ! T2-based image ! Attenuates the bright signal of CSF on
the usual T2 image ! White matter = gray ! Gray matter = white
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Comparison (non-contrast)
T1 T2 FLAIR
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Comparison (non-contrast)
T2 FLAIR
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Vasogenic and Cytotoxic Edema Vasogenic Cytotoxic
! Reactive process ! Bilateral if toxic ! Unilateral if surrounding
a mass lesion ! Predominantly white
matter ! Improves with steroids
! Primary process, tissue injury
! Unilateral or bilateral ! Affects gray and white
matter ! Does not respond to
corticosteroids
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DWI
! Diffusion of water is rapid in normal brain parenchyma and in vasogenic edema (normal signal)
! Diffusion is restricted in cytotoxic edema (bright signal)
! Apparent diffusion coefficient (ADC) is used to verify diffusion restriction versus artifact
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DWI/ADC ! Non-invasive, physiologic imaging
! Highly sensitive to tissue injury " More sensitive than T1/T2/FLAIR " Can show cerebral ischemia within minutes
! ADC correlation " Acute vs. chronic infarct " Infarct vs. artifact " Cytotoxic vs. vasogenic edema
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DWI/ADC
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Cytotoxic Edema on MRI
DWI ADC
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Acute Ischemic Stroke
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Acute Ischemic Stroke
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Acute Ischemic Stroke
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Acute Ischemic Stroke
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Acute Ischemic Stroke
FLAIR DWI ADC
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Cerebral Metastatic Disease
FLAIR DWI ADC
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Cerebral Metastases
GRE T1 +C
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
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Hydrogen Peroxide Ingestion
FLAIR DWI ADC
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Hydrogen Peroxide Ingestion
FLAIR DWI ADC
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Hydrogen Peroxide Ingestion
FLAIR DWI ADC
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Hydrogen Peroxide Ingestion
FLAIR DWI ADC
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Hydrogen Peroxide Ingestion
FLAIR DWI ADC
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Posterior Reversible Encephalopathy Syndrome
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Posterior Reversible Encephalopathy Syndrome
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Posterior Reversible Encephalopathy Syndrome
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Posterior Reversible Encephalopathy Syndrome
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Posterior Reversible Encephalopathy Syndrome
FLAIR DWI ADC
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Posterior Reversible Encephalopathy Syndrome
FLAIR DWI ADC
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Posterior Reversible Encephalopathy Syndrome
FLAIR DWI ADC
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Posterior Reversible Encephalopathy Syndrome
FLAIR DWI ADC
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PRES – 4 Months Later
Initial FLAIR Follow-up FLAIR
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PRES – 4 Months Later
FLAIR DWI ADC
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Delayed Post-Hypoxic Leukoencephalopathy - Heroin
FLAIR DWI ADC
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Delayed Post-Hypoxic Leukoencephalopathy - CO
FLAIR DWI ADC
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
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Hypoxic-Ischemic Injury
FLAIR DWI ADC
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Hypoxic-Ischemic Injury
FLAIR DWI ADC
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Hypoxic-Ischemic Injury
FLAIR DWI ADC
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Hypoxic-Ischemic Injury
FLAIR DWI ADC
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MRI Summary
! FLAIR- white matter edema, demyelination, inflammation, infarction
! DWI/ADC- cytotoxic vs. vasogenic edema
! T1- metal deposition (copper, manganese)
! GRE- hemosiderin ! Gadolinium contrast- BBB breakdown
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MRS ! Phosphorus ! Inorganic
phosphorus, ATP ! Measures energetic
state, pH ! Healthy tissue
(Krebs cycle) vs. Ischemic tissue (glycolysis)
! Proton ! Three usual peaks:
" Creatine (Cr) " Choline (Cho) " N-acetyl aspartate
(NAA)
! Lactate
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MRS
! Creatine " Relatively constant
! Choline " Elevated with increased cellular turnover
(e.g. neoplasm) ! NAA
" Decreased in neuronal injury (e.g. infarction) ! Lactate
" Increased in inflammation, infarction
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MRS Profiles
Myo-inositol
Choline NAA Lactate
High grade tumor
++ +++ - - -
Necrotic/treated tumor
- - - -
HIE - +
Acute Demyelination
++ ++ -
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Classic findings
! Demyelination " Decreased NAA, Elevated Cho
! Alzheimer Disease " Elevated Myoinositol
! Meningiomas " Elevated Alanine
! Canavan Disease " Markedly elevated NAA
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Classic findings
! Doublet lactate peak " Stroke " Seizure (recent) " High-grade or necrotic neoplasms
! Hypoxic-ischemic encephalopathy " Elevated lactate, Decreased NAA
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Clinical Uses of MRS
! Neoplasm or not ! Recurrent neoplasm vs. radiation
necrosis ! Etiology of leukoencephalopathy ! Evaluating for metabolic disease
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Slides withheld ! Images of MRS from literature withheld ! See the following references:
" Chen-Plotkin AS, et al. “Delayed leukoencephalopathy after hypoxic-ischemic injury.” Arch Neurol 2008: 65(1): 144-5
" Gottfried JA, et al. “Delayed posthypoxic demyelination: association with arylsulfatase A deficiency and lactic acidosis on proton MR spectroscopy.” Neurology 1997: 49: 1400-4.
" Chang WC, et al. “MRI features of spongiform leukoencephalopathy following heroin inhalation.” Neurology 2006; 67: 504.
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SPECT and Cerebral Blood Flow Study
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Nuclear Medicine ! Infuse radioactive compounds, then detect
emissions with gamma cameras ! Technetium
" Cerebral Blood Flow Study ! Indium (CSF)
" Hydrocephalus study " Sinonasal CSF leak study
! Positron-emitting isotopes " Deoxyglucose PET " Dopamine PET
! SPECT
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Cerebral Blood Flow
! Technetium 99m-HMPAO
! Planar imaging
! Imaging delayed after infusion
! In brain death, no tracer accumulates = “cold study”
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CBF
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CBF
! See the following reference for additional images: " Laurin NR, et al. “Cerebral Perfusion
Imaging with Technetium-99m HM-PAO in Brain Death and Severe Central Nervous System Injury.” J Nucl Med 1989; 30: 1627-35.
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SPECT
! Single photon-emission computed tomography
! Iodinated radiotracer or technetium agents
! Less expensive than PET " Agents are more stable " No cyclotron required
! Stroke, Epilepsy, Dementia, Parkinsonism
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SPECT in Parkinsonism
! Radiotracer can be labeled for pre- or post-synaptic sites
! Presynaptic " DAT " VMAT " AADC
! Postsynaptic " D1 or D2 receptor
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SPECT in Parkinsonism
! See the following reference for images: " Huang CC. “Parkinsonism induced by
chronic manganese intoxication – an experience in Taiwan.” Chang Gung Med J 2007; 30: 385-95
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Summary ! MR Spectroscopy – White matter lesion
of unknown etiology
! SPECT – Differentiation of toxin-induced vs. idiopathic parkinsonism
! Cerebral blood flow studies –
Confirmatory testing for brain death determination in poisoned patient