Neuroradiology for the ED
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Transcript of Neuroradiology for the ED
NEURORADIOLOGYTRUDY ROSS
RADIOLOGY DEPARTMENT
APPROACH TO THE CT BRAIN
• Ventricles and subarachnoid spaces• Basal cisterns• Asymmetry• Abnormal density• Grey-white matter differentiation• Bones and soft tissues
CHOOSE YOUR WINDOW
BASIC MR
• Basic features:• Fluid – T2 very bright• Haemorrhage – Varies with time, often hard to see,
blooming on GRE• Oedema – T1 dark, T2 bright• Fat – Bright T1 and T2• Can have Fat suppressed sequences (T2 FS bright =
oedema); or Fluid attenuated sequences (FLAIR – abnormal oedema is bright)
• FIR, STIR, FIESTA, GRE …….
IMAGING STRATEGIES – INDICATIONS FOR BRAIN IMAGING
• Non contrast for bleed, ventricles or stroke• Give contrast for masses, abscesses, dural venous sinuses.
Scan performed at approx 2min.• Angiogram – for assessment of arterial supply. High flow
rate, timed for opacification of the cerebral arteries. • MR – much better anatomical detail. More sensitive to
slight changes in tissue. Not as useful for bleeds or bone
HAEMORRHAGE
• Extradural• Subdural Extra-axial• Subarachnoid
• Contusion Intra-axial• DAI
DENSITY (HU)
Air < -500Fat -50CSF 0WM/GM 30/40ACUTE BLOOD 70Calcification >150Bone >500
BLOOD ON CT
• Acute: hyperdense• Subacute: Isodense• Chronic: hypodense• Hyperacute blood can be dark.
EXTRADURAL
• Lifts dura off inner table of skull• Fracture in 90% • Usually arterial from rupture of MMA. Can be venous
(10%).• Biconvex/lentiform. Doesn’t cross suture lines unless there
is diastasis.• 95% supratentorial
ACUTE EPIDURAL
T2T1
SUBDURAL HAEMORRHAGE
• Stretching/tearing of bridging cortical veins• 95% supratentorial, 15% bilateral• Cross sutures but not dural attachments (will never cross
midline)• Crescentic• Common in infants (child abuse) and elderly• Density change with age of haemorrhage.• Rebleeding may cause a heterogenous appearance ;
sediment level or haematocrit effect
Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 16807
Case courtesy of Dr Lawrence Chia Wei Oh, Radiopaedia.org, rID: 24512
Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 30404
SUBDURAL HAEMATOMA
T1T2PD
SUBDURAL HAEMATOMA
T2 T1 T1 + contrast
SUBARACHNOID HAEMORRHAGE• Aneurysm most common cause• Other causes
• trauma• Vascular malformation …
• Look for high density in CSF cisterns, interpeduncular fossa, sylvian fissure, sulci, ventricles. May be very tiny, especially in the setting of trauma.
• 95% positive in 1st 24 hours, < 50% by 1 week
RIGHT MCA BIFURCATION ANEURYSM
INTRA-AXIAL HAEMORRHAGE
• Diffuse Axonal Injury (DAI)- Significant cause of morbidity in severe closed head injury
- Axonal shearing injury and depolarisation
- Lobar WM-GW interface, CC, dorsolateral upper brainstem
- Only 20-50% abnormal on initial CT, petechial haem
INTRA-AXIAL HAEMORRHAGE
• Contusion- Brain striking bony ridge
- Acceleration/deceleration injury
- Occur in characteristic locations; temporal lobe, frontal lobe, parasagittal
- Coup + Contra-coup injury
• Hypertensive haemorrhage• 50% of nontraumatic ICHs caused by hICH
• Putamen/external capsule (60-65%)• Thalamus (15-25%)• Pons, cerebellum (10%)• Lobar (5-10%)• Multifocal "microbleeds" (1-5%)
• Heterogeneous density if coagulopathy or active bleeding• Other findings
• Intraventricular extension• Mass effect: Hydrocephalus, herniation
INTRA-AXIAL HAEMORRHAGE
DIFFERENTIALS• Cerebral Amyloid Angiopathy
• Lobar > > basal ganglionic• Usually elderly, often normotensive• But as HTN is so common it is still the most common cause of
lobar ICH• Vascular Malformation
• Patients usually normotensive, younger• Most common = cavernous malformation• Less common = thrombosed hemorrhagic AVM or dAVF
• Cocaine• Usually still basal ganglia, • Hypertensive mechanism
DIFFERENTIALS CONT..• Coagulopathy
• Elderly patients on anticoagulant therapy• Venous Thrombosis
• May have history of dehydration, "flu," pregnancy/OCP• Cause lobar hematomas• Look for hyperdense dural sinus (not always present)
• Deep Cerebral Venous Thrombosis• Less common than dural sinus or cortical vein thrombosis• Look for hypodense bilateral thalami• Look for hyperdense internal cerebral veins, intraventricular
hemorrhage• Hemorrhagic Neoplasm
• Secondary (metastasis) and primary (GBM)
COMPLICATIONS OF BLEEDS
• Hydrocephalus• Herniation• Vasospasm and infarct
HYDROCEPHALUS
HERNIATION
VASOSPASM
THROMBOEMBOLIC STROKE
• <12hrs : >50% norm, Hyperdense art• 12-24rs : Low dens, GW diff loss, Sulcal effacement• 1-3 days : mass effect, low density of G&W• 4-7 days : gyral enhancement, mass effect/oedema• 1-8/52: contrast enhancement, mass effect resolves• Months-yrs: encephalomalacia, volume loss, Calc rare
VASCULAR TERRITORIES
MCA
ACA
PCA
ACUTE SIGNS
• Hyperdense vessel• Insular ribbon sign• Obscuration of lentiform nucleus• Hypoattenuating brain• Loss of grey-white differentiation• Loss of sulcation
HYPOATTENUATING BRAIN LOSS OF SULCATION
• Failure of ion pumps cause increased brain water
• Irreversible damage
• Bad sign if seen in the first 6hrs
BLURRED BASAL GANGLIA
• Loss of definition of the basal ganglia
• One of the earliest and most frequently seen signs
• MCA infarction
INSULAR RIBBON SIGN
• Very sensitive to ischaemia
• A subtle but early sign• MCA territory
DENSE VESSEL
• Due to thrombus or embolus in the artery
IS IT OLD???
• Well defined• Hypodense• Negative mass effect• Ex vacuo dilation
CT PERFUSION
• CBF• CBV• MTT• Blue always low
value, red high value
MRI IN STROKE
• T2 and FLAIR hyperintensity = cell death • Will detect 80% in first 24hrs• Can be normal first 2-4hrs
• DWI• Normally water protons can diffuse between
compartments. Cytotoxic oedema disrupts this. “Restricted diffusion”.
• Most sensitive sequence for acute stroke
AGING BRAINS
SMALL VESSEL ISCHAEMIC CHANGES• Grade 1 is
normal.• 2 and 3 are
pathologic but can be seen in normal functioning people.
• Strong predictor of rapid global functional decline
RING ENHANCING LESIONS
RING ENHANCING LESIONS
• Long differential• Abscess• Tumour (primary or secondary)• Haematoma• Stroke• Tumefactive MS• Radiation necrosis• Resection cavity
SPINE
SPINAL IMAGING - APPROACH
• As for plain films, but more components visible in CT/MR• Alignment + number of vertebral bodies• Vertebral body and intervertebral disc heights• Joints – Atlanto-occipital, Atlanto-axial, Facet joints• Spinal canal• Spinal cord –
• conus termination; • cord signal, • nerve roots• If mass lesion – intra-axial (Cord) or extra-axial (Dural, bony)
GET THE MODALITY RIGHT
NORMAL DISC
DEGENERATIVE DISC
• Decreased height• Bulging• Gas bubbles• Endplate change• Happens from an early age• Osteophytes• Facet joint changes
FOCAL VS BROAD BASED BULGE
• Protrusion vs extrusion
• • Migration vs • sequesteration
• Central • Paramedian/lateral recess – most common• Foraminal – 5-10% but cause severe pain• Lateral - uncommon
DISC HERNIATION
FORAMINAL DISC PROTRUSION
TERMS
• Spondylosis – degenerative change between vertebral bodies or at zygopophyseal joints
• Spondylolysis – a pars interarticularis defect, usually a stress fracture.
• Spondylolisthesis – slipping of vertebrae, often due to spondylolysis
• Spondylitis – inflammation of the vertebrae eg AS
CERVICAL SPINE STENOSIS DUE TO CERVICAL SPONDYLOSIS
OSTEOARTHRITIS SPINE
• Uncovertebral joints• Facet joints• Intervertebral discs
• Compression on nerves can be just disc herniation, just productive OA changes or a combination of both (disc osteophyte complex)
FINISHED!!!