MRI OF THE BRAIN, HEAD, NECK AND SPINE

SERIES IN RADIOLOGY

J. Odo Op den Orth, The Standard Biphasic-Contrast Examination of the Sto­mach and Duodenum: Method, Results and Radiological Atlas. 1979. ISBN 90 247 2159 8

J.L. Sellink and R.E. Miller, Radiology of the Small Bowel. Modern Enterocly­sis Technique and Atlas. 1981. ISBN 90 247 2460 0

R.E. Miller and J. Skucas, The Radiological Examination of the Colon. Practi­cal Diagnosis. 1983. ISBN 90 247 2666 2

S. Forgacs, Bones and Joints in Diabetes Melitus. 1982. ISBN 90 247 2395 7

G. Nemeth and H. Kuttig, Isodose Atlas. For Use in Radiotherapy. 1981. ISBN 90 247 2476 7

J. Chermet, Atlas of Phlebography of the Lower Limbs, including the Iliac Veins. 1982. ISBN 90 247 2525 9

B. Janevski, Angiography of the Upper Extremity. 1982. ISBN 90 247 2684 0

M.A.M. Feldberg, Computed Tomography of the Retroperitoneum. An Ana­tomical and Pathological Atlas with Emphasis on the Fascial Planes. 1983. ISBN 0 89838 573 3

L.E.H. Lampmann, S.A. Duursma and J .H.J. Ruys, CT Densitometry in Osteo­porosis. The Impact on Management of the Patient. 1984. ISBN 0 89838 633 0

J.J. Broerse and T.J. MacVittie, Response of Different Species to Total Body Irradiation. 1984. ISBN 0 89838 678 0

C. L'Hermine, Radiology of Liver Circulation. 1985. ISBN 0 89838 715 9

G. Maatman, High-resolution Computed Tomography of the Paranasal Sinuses, Pharynx and Related Regions. 1986. ISBN 0 89838 802 3

C. Plets, A.L. Baert, G.L. Nijs and G. Wilms, Computer Tomographic Imaging and Anatomic Correlation of the Human Brain. 1986. ISBN 0 89838 811 2

J. Valk, MRI of the Brain, Head, Neck and Spine. A Teaching Atlas of Clinical Applications. 1987. ISBN 0 89838 957 7

J.L. Sellink, X-Ray Differential Diagnosis in Small Bowel Disease. A Practical Approach. 1987. ISBN 0 89838 351 X

T.H.M. Falke, ed., Essentials of Clinical MRI. 1988. ISBN 0 89838 353 6

MRI OF THE BRAIN, HEAD, NECK AND SPINE

A teaching atlas of clinical applications

JAAP VALK Department of Neuroradiology, Academic Hospital,

Free University of Amsterdam, The Netherlands

with contributions by

JONAS A. CASTELIJNS and MARJO S. VAN DER KNAAP

1987 MARTINUS NIJHOFF PUBLISHERS ~ ... a member of the KLUWER ACADEMIC PUBLISHERS GROUP .It DORDRECHT / BOSTON / LANCASTER

Distributors

jonhe United States and Canada: Kluwer Academic Publishers, P.O. Box 358, Accord Station, Hingham, MA 02018-0358, USA jor the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LA1 1RN, UK jor all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands

Library of Congress Cataloging in Publication Data

Valk, J. MRl of the brain, head, neck. and spine. (Series in radiology) Bibliography: p. I. Magnetic resonance imaging. 2. Brain--Diseases-­

Diagnosis. 3. Head--Radiography. 4. Neck--Diseases-­Diagnosis. 5. Spine--Diseases--Diagnosis. I. Castelijns, Jonas A. II. Knaap, Marjo S. van der. III. Title. IV. Series. [DNLM: I. Brain--pathology-­atlases. 2. Head--pathology--atlases. 3. Neck-­pathology--atlases. 4. Nuclear Magnetic Resonance-­diagnostic use--atlases. 5. Spine--pathology--atlases. WB 17 VI7ml RC386.6.M34V35 1987 617' .510754 87-16854

ISBN-13: 978-94-010-8005-7 e-ISBN-13: 978-94-009-3351-4 001: 10.1007/978-94-009-3351-4

Copyright

© 1987 by Martinus Nijhoff Publishers, Dordrecht. Softcover reprint of the hardcover 1 st edition 1987

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers, Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht, The Netherlands.

ABBREVIA TIONS

FOREWORD

l. INTRODUCTION l.l. Introduction 1.2. Basic principles of MRI

2. TECHNICAL CONSIDERATIONS

CONTENTS

XIII

3 5 5

9 2.1. Pulse sequences 10

5. MRI cisternography 10 6. Tissue differentiation, same slice, different techniques, IR, SE, SE with

Gd-DTPA 12 7. Tissue differentiation in complex pathology 8. 'Anatomical' sequence, short TR, short TE 9. Application of' anatomical' sequence

2.2 Artefacts 10. Artefacts (l) 11. Artefacts (2) 12. Artefacts (3)

2.3. Functional studies 13. Functional studies on MRI systems

2.4. Flow related phenomenons 14. Signal void in aqueduct

15,16. Flow-void in aqueduct; NPH 17. Flow-void in aqueduct; hydrocephalus in infants 18. CSF flow obstruction 19. Arteriovenous malformation 20. Flow phenomena, carotid artery

2.5. Surface coils 21,22,

23. Surface coils (1) 24. Surface coils (2) 25. Surface coils (3), coronal and oblique images 26. Surface coils (4), orbit, oblique sagittal views

3. SPECIAL PROCEDURES 3.1. Sellar and parasellar regions

27. Empty sella 28, 29. Pituitary adenomas

30. Chromophobe adenoma 31. Parasellar lesion 32. Para sellar lesion

3.2. Mesencephalon, region pineal gland 33. Pinealoma

14 16 18

20 20 22 24

26 26

28 28 30 32 33 34 35

36 36 36 38 39 40

43 44 45 46 48 50 52

54 54

VI

3.3 Pontocerebellar cisterns 34. Coronal T2W, thin section series 35. Pontocerebellar cistern: T2W images; MRI cisternography

36,37. Acustic neurinomas 38. Acustic neurinoma

4. INTRACRANIAL TUMOURS 4.1. Diagnostic problems

4.2. Cerebral tumours 39. Localization; intraventricular meningeoma 40. Cyst or solid? 41. Oligodendroglioma; large linear calcifications 42. Low grade glioma 43. Malignant glioma 44. Malignant glioma, patchy enhancement 45. Multifocal astrocytoma 46. Posterior fossa tumour

4.3. Extracerebral tumours 47. Medulloblastoma 48. Suprasellar lesion, craniopharyngeoma 49. Parasellar meningeoma

4.4. High SI lesions in pons and mesencephalon 50. Intrapontine haematoma; glioma 51. Intrapontine haemorrhage, dd. dermoid cyst 52. Same patient as in 51; follow-up 53. Dermoid cyst 54. Same patient as in 53; follow-up

4.5. Metastases 55. Metastases and Gd-DTPA 56. Metastasis of adenocarcinoma with haemorrhage 57. Tissue characterization; adenocystic carcinoma, metastasis

4.6. Gliomatosis cerebri 58. Multifocal astrocytoma or gliomatosis cerebri 59. Gliomatosis diffusa 60. Gliomatosis diffusa 61. Gliomatosis diffusa 62. Vasculitis simulating gliomatosis diffusa 63. Gliomatosis diffusa 64. Gliomatosis diffusa; cerebellar involvement 65. Gliomatosis diffusa

5. SPINAL LESIONS 5.1. Spondylarthrotic and disc related disease

66. Spondylarthrotic and disc related disease 67. Spondylarthrotic and disc related disease

68, 69. Myelopathy due to compression 70. Herniated disc L5-S 1 71. Postoperative lumbar spine

56 56 58 60 62

65 68

70 70 72 74 76 78 80 82 84

86 86 88 90

92 92 94 96 98

100

102 102 104 106

109 110 112 114 116 118 120 122 122

127 130 130 131 132 134 136

VII

5.2. Orthopedic problems 138 72. Orthopedic problems 138 73. Orthopedic problems 140

5.3. Spinal tumours 143 5.3.1. Intramedullary tumours 144

74. Intramedullary tumour, lipoma/dermoid 144 75. Intramedullary tumour 146 76. Cystic tumour, craniovertebral region 148 77. Intramedullary tumour and syrinx 150 78. Intramedullary tumour (metastasis) 152 79. Intramedullary tumour and cysts 154 80. Recurrent intramedullary astrocytoma Gd-DTPA 156 81. Intramedullary tumour, ependymoma with calcifications 158 82. Whole cord spinal tumour, astrocytoma, grade 2, recurrence 160 83. Intramedullary tumour, astrocytoma grade 1 162 84. Intradural dermoid cyst and lipoma 164 85. Cystic ependymoma (post-operative) 166 86. Intramedullary tumour without and with Gd-DTPA 168 87. Mutiple lesions; intramedullary tumour 170

5.3.2. Vascular malformations 172 88. Intramedullary lesion. Cryptic angioma? 172 89. Intramedullary arteriovenous malformation 174

5.3.3. Extramedullary and extradural lesions 176 90. Meningeoma at the Cl level 176 91. Osteochondroma of posterior arch 178 92. Extradural expanding lesion, Schwannoma 180 93. Post-laminectomy Th 1-2 for metastasis of adenocarcinoma of the breast 182 94. Metastasis of breast carcinoma 184 95. Giant cell tumour in sacrum 186 96. Extramedullary compression. Non Hodgkin lymphoma 187 97. Extradural lesion with cord compression. Osteoporosis of vertebral column 188

5.3.4. Congenital malformations, Myelodysplasia 190 98. Chiari 1+, syrinx 190 99. Chiari I and syringomyelia 192

100. Spondylolysis and listhesis 194 101. Tethered cord, lipoma, syrinx 196 102. Tethered cord, intra-extradural lipoma 198 103. Tethered cord, hydronephrosis 200 104. Myelodysplasia; diastematomyelia 202 105. Myelodysplasia; diastematomyelia 204 106. Sacral cyst 206

6. CONTRAST AGENTS 209 107. Virus infection 211 108. Metastatic disease 216 109. Metastatic disease 218 110. Low grade astrocytoma 220 111. Glioma, grade 3; postoperative, postradiotherapy 222 112. Glioblastoma multiforme, distinction between tumour/oedema 224

VIII

113. Cystic or solid lesion 114. Meningeoma of the foramen magnum 115. Tentorium meningeoma 116. Intramedullary tumour 117. Recurrent spinal meningeoma 118. Intramedullary tumour 119. Intra- or extramedullary lesion with arachnoiditis 120. Intramedullary lesion in Wegener's disease 121. Same patient as in 120, follow-up after treatment

226 228 230 232 234 236 238 240 242

7. INFECTIONS 245 247 248 250 252 254 256 258 260 262

7.1. General 122. N eurocysticercosis 123. Viral encephalitis 124. Tuberculoma with partial epileptic seizures 125. Tuberculous meningitis 126. Postencephalitic changes; herpes simplex encephalitis 127. Empyema, infectious sinus thrombosis, infarctions 128. Septicaemia, meningoencephalitis 129. Transverse myelitis

7.2. AIDS encephalopathy 130. AIDS related disease 131. AIDS dementia-complex; encephalitis 132. AIDS encephalopathy 133. AIDS encephalopathy 134. AIDS encephalitis 135. AIDS dementia-complex

264 264 266 268 270 272 274

8. VASCULAR LESIONS 277 8.1. Cerebral infarctions 278

136. Infarction or astrocytoma 280 137. Middle cerebral artery infarction 282 138. Multiple infarctions 284 139. Anterior cerebral artery infarction; lymphoma; haemorrhage 286 140. Anterior cerebral artery infarction; recurrent artery of Heubner infarction 288 141. Old deep middle cerebral artery infarction 289

142, 143. Border zone infarctions 290 144, 145. Border zone infarction; dd. MS 292

146. Border zone infarction 294 147. Old infarction of middle cerebral artery (MCA); recent infarction of the basi-

lar artery territory 296

8.2. Cryptic angiomas 298 148. Cryptic angiomas 298 149. Cryptic angiomas; multiple echoes 300

150, 151. Cryptic angiomas 302

8.3. A VM's, aneurysms, intracerebral haemorrhage 304 152. Arteriovenous malformation 304 153. Basilar artery aneurysm or suprasellar tumour 306 154. Intracerebral haematoma 308

8.4. Deep white matter infarctions, Binswanger's disease, Multi infarct dementia 155. Psychiatric syndrome and white matter abnormalities 156. Binswanger's disease? 157. Multi-infarct dementia 158. Binswanger's disease 159. Binswanger's disease; Fe++ in basal ganglia

9. WHITE MATTER DISORDERS-MYELINATION 9.1. De- and dysmyelination

160. Adrenoleukodystrophy 161. Fukuyama's disease; congenital musclular dystrophy, leukodystrophy 162. Leukodystrophy post-irradiation

9.2. Multiple sclerosis 163. Multiple sclerosis 164. Multiple sclerosis, multiple echoes 165. Multiple sclerosis? 166. Multiple sclerosis 167. Multiple sclerosis. Cervical cord lesions 168. Multiple sclerosis. Acute hemiparesis Gd DTPA 169. Multiple sclerosis (and Normal Pressure Hydrocephalus) 170. Internuclear ophthalmoplegia

9.3. Toxic encephalopathy 171. Toxic encephalopathy 172. Toxic encephalopathy 173. Toxic encephalopathy 174. Toxic (allergic) encephalopathy 175. Toxic encephalopathy after heroin 176. Toxic encephalopathy 177. Alcohol abuse

9.4. Myelination 178. Standard series 179. Myelination at 6 weeks in IR

180a, b. Myelination at 3 months, IR and SE 181a. Myelination at 6 months, IR 181 b. Myelination at 8 months, IR 18le. Myelination at 8 months, SE, TE 30 181d. Myelination at 6 months, TE 120

182. Myelination at 9 months, IR 183a. Myelination at 18 months, IR

183b, 184. Myelination at 18 months, SE 185. Myelination at 2 years" IR

186a,b. Congenital malformation. Myelination in accordance with age 187a. Microcephaly, partial holoprosencephaly. Myelination

I 87b,c. Microcephaly, partial holoprosencephaly. Myelination 188. Hypomyelination, Pelizaeus Merzbacher's disease 189. Hydrocephalus, retrocerebellar cyst, delayed myelination (?) 190. Hydrocephalus and retarded myelination 191. Mental retardation, physically handicapped

IX

310 310 312 314 316 318

321 322 324 326 328

331 332 334 336 338 340 342 344 346

348 348 350 352 354 356 358 360

362 364 366 368 370 371 372 373 374 375 376 378 380 382 383 384 386 388 390

x

192. Pelizaeus Merzbacher 193. Pelizaeus Merzbacher 194. Metachromatic leukodystrophy

10. CONGENITAL ANOMALIES with Marjo S. van der Knaap 195. Total vermis aplasia, hydrocephalus, abnormal optic chiasm 196. Schizencephaly 197. Encephaloclastic schizencephaly 198. Lissencephaly, pachygyria 199. Multiple congenital malformations; periventricular leukomalacia 200. Holoprosencephaly 201. Hemimegencephaly 202. Hemimegencephaly 203. Bourneville-Pringle's disease, tuberous sclerosis 204. Unclassifiable. Congenital hydrocephalus? 205. Agenesis of corpus callosum. Cerebellar infarction 206. Arachnoid cyst 207. Peri ventricular leukomalacia 208. Peri ventricular leukomalacia 209. Post encephalitic remains 210. Chiari II malformation 211. Congenital muscle dystrophy and leukodystrophy (Fukuyama) 212. Corpus callosum agenesis. Plexus papilloma 213. Lipoma of the corpus callosum

11. LESIONS OF THE HEAD AND NECK 214. Adenocystic tumour nasopharynx 215. Follow-up after cytostatic treatment of adenocystic tumour of the

nasopharynx 216. Adenocarcinoma of nasopharynx 217. Tumour of the palatum 218. Tumour of the palatum 219. Parotid gland disease 220. Tumour os temporale; metastasis in skull 221. Cyst in the neck region 222. Pleomorph adenoma of submandibular gland 223. Rhabdomyosarcoma of the neck 224. Palatum tumour 225. Clivus chordoma? Grawitz tumour metastasis? 226. Chordoma 227. Chordoma

12. LARYNGEAL CANCER by Jonas A. Castelijns 228. Hypopharyngeal tumour 229. Small supraglottic tumour with lymphatic spread 230. Small glottic tumour

13. ORBITAL AND OCULAR LESIONS 231. Retinoblastoma 232. Melanotic melanoma 233. Amelanotic melanoma

392 394 396

399 404 406 408 410 412 414 416 418 420 422 424 426 428 430 432 434 436 438 440

441 445

452 454 456 456 458 459 460 462 464 466 468 470 472

475 478 480 482

485 487 488 490

XI

234. Optic glioma 492 235. Carcinoma of the lacrimal gland 494

236,237. Reduced size of eye: persistent hyperplastic vitreous; post-radiotherapy 496 238,239, 240,241. Various lesions 498

242. Aplasia of orbital roof 500 243. Coloboma of the eye 502 244. Outer ridge meningeoma 503

14. TEMPOROMANDIBULAR JOINT 505 245. Anterior luxation with reduction 508 246. Rotational dislocation 510

15. TRAUMA 513 247. Chronic subdural haematoma 516 248. Bilateral subdural haematomas; tentorial herniation 518 249. Haemorrhagic contusions 520

16. EPILEPSY 250. Fronto-opercular gliosis with calcification and retraction 251. Low-grade astrocytoma; no progression in two years 252. Peri-insular gliosis 253. Refractory partial epilepsy; gliosis of the temporal lobe 254. Partial complex epilepsy; temporal lobe atrophy

17. POSTOPERATIVE CONDITIONS 255. Haemochromatosis and Normal Pressure Hydrocephalus 256. Postoperative control parana sal squamous cell carcinoma 257. Oligodendroglioma postoperative 258. Non Hodgkin lymphoma in pre-existent intraventricular cyst 259. Intramedullary haemangioblastoma with syrinx 260. Spinal syrinx after compression

18. GRADIENT ECHOES 261. Gradient echoes 262. Gradient echoes

ACKNOWLEDGEMENTS

REFERENCES

INDEX

523 526 528 529 530 532

535 536 538 540 542 544 546

547 549 549

552

554

569

ABBREVIATIONS

In this book the following abbreviations are frequently used:

IR = InVerSIOn recovery SE = spin echo TI = inversion time TE = echo time TlW = Tl weighted IW = intermediate weighted (balanced image) T2W = T2 weighted RF = radio frequency Mz = magnetization along the z-axis; M represents the net magnetization of the magnetizations of

the protons, aligned parallel or anti parallel to the main magnetic field. NSQ = number of sequences EEG = electro encephalography VER = visual evoked response BER = brain stem evoked response SI = signal intensity CT = computed tomography US = ultrasonography VPD = ventriculo peritoneal drainage TMJ = temporomandibular joint DSA = digital subtraction angiography IACA = inferior anterior cerebellar artery lAC = internal auditory canal CE = contrast enhancement

FOREWORD

With the growing number of MR installations, clinicians and radiologist are being confronted more and more with visual information they do not feel as confident with as with the more 'mono-form' infor­mation of conventional radiographs, CT and US.

The freedom of parameter choice ofthe MR operator allows the same object to be depicted in various ways and the contrast in the images to be changed and inverted at will. For those not experienced in interpreting MR images, this may cause confusion and uncertainty about their diagnostic content. This will sometimes lead to an unnecessary retreat to other diagnostic modalities.

The purpose of this book is to help close the gap between MR operators and readers and clinicians. A variety of cases is presented, together with the MRI considerations. In nearly all these cases, confirma­tion of diagnosis was obtained by histological examination.

Quite deliberately, this book only includes the occasional CT scan or angiography for comparison, to avoid the temptation of falling back on other modalities and of escaping from the often more difficult to interpret, but in the end more rewarding MR images.

All the MR images in this book were made with a 'first-generation', unsophisticated Teslacon I, 0.6 T, superconducting magnet system. Hopefully, they will reflect the quality of the machine. Some people will agree with me that it is sad that investments in expensive health care systems are subject to the whims of those who are mainly interested in satisfying their stockholders.

I would like to express my gratitude to all the colleagues who have referred their patients to our department and in so doing have contributed to our experience with MRI. The many discussions have certainly helped to shape our knowledge. The form of a teaching atlas has been chosen: cases are presented with relevant images within a certain context. It does not boast full coverage of every subject, but tries to stimulate thinking about the MR imaging process in relation to pathology.

It is to be hoped that this volume will reach many colleagues who are also interested in this fascina­ting medium, MRI.

Amsterdam; 1987, J. Valk