Tumors and Vascular diseases of the Brain.ppt
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Transcript of Tumors and Vascular diseases of the Brain.ppt
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Tumors and Vascular Tumors and Vascular diseases of the Braindiseases of the Brain
April 3, 2008April 3, 2008
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Jennifer Villa Frabizzio, Jennifer Villa Frabizzio, M.D.M.D. Abington Memorial HospitalAbington Memorial Hospital Radiology Group of Abington, PCRadiology Group of Abington, PC
Board Certified in Diagnostic Board Certified in Diagnostic Imaging with Added Qualifications Imaging with Added Qualifications in Neuroradiologyin Neuroradiology
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Topics for DiscussionTopics for Discussion
NeuroimagingNeuroimagingThen and NowThen and Now
NeuroanatomyNeuroanatomy Vascular and Nonvascular Vascular and Nonvascular
Vascular DisordersVascular DisordersDiagnosis and TreatmentDiagnosis and Treatment
TumorsTumorsPrimary and Metastatic DiseasePrimary and Metastatic Disease
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Neuroimaging- ThenNeuroimaging- Then
Standard RadiographStandard Radiograph
PneumoencephalographyPneumoencephalography
Direct Cerebral AngiographyDirect Cerebral Angiography
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PneumoencephalograhPneumoencephalograhyy Introduced in 1919 by American Surgeon Introduced in 1919 by American Surgeon
Dandy WalkerDandy Walker Primary method of Neurodiagnosis used late Primary method of Neurodiagnosis used late
until late 1970’s early 1980’suntil late 1970’s early 1980’s Lumbar puncture performed in sitting Lumbar puncture performed in sitting
positionposition Patient placed in somersault chair with head Patient placed in somersault chair with head
suspended in harnesssuspended in harness CSF removed and 10-15 mls of air introducedCSF removed and 10-15 mls of air introduced Patient is tilted upside down and 50-60 mls Patient is tilted upside down and 50-60 mls
more air introducedmore air introduced
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PneumonecephalograpPneumonecephalography cont.hy cont. Air outlined brainstem structures and supra Air outlined brainstem structures and supra
tentorial structures to diagnose masses, tentorial structures to diagnose masses, tumors and cerebral atrophytumors and cerebral atrophy
Very time consuming, could take from one to Very time consuming, could take from one to two hours to performtwo hours to perform
Following the procedure patients invariably Following the procedure patients invariably developed severe headache and maybe a developed severe headache and maybe a feverfever
Sampling of CSF post procedure showed high Sampling of CSF post procedure showed high protein and white blood cells, which seemed to protein and white blood cells, which seemed to be a response to the airbe a response to the air
Symptoms would usually resolve within 48hrsSymptoms would usually resolve within 48hrs
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Direct Cerebral Direct Cerebral ArteriographyArteriography Pioneered in 1927 by Dr. Egas MonizPioneered in 1927 by Dr. Egas Moniz Needle was inserted directly into the Needle was inserted directly into the
common carotid artery in the neck and common carotid artery in the neck and contrast material injectedcontrast material injected
Rapid series of radiographs were taken Rapid series of radiographs were taken of the skull in numerous projectionsof the skull in numerous projections
Currently studies are preformed by Currently studies are preformed by inserting a catheter into the femoral inserting a catheter into the femoral arteryartery
Remains as gold standard for imaging Remains as gold standard for imaging arterial and venous structuresarterial and venous structures
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Neuroimaging-NowNeuroimaging-Now
Computed Axial TomographyComputed Axial Tomography– CAT SCANCAT SCAN
Magnetic Resonance ImagingMagnetic Resonance Imaging– MRIMRI
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Computed Computed TomographyTomography From Greek tomos (slice) and graphein (to write)From Greek tomos (slice) and graphein (to write) Generation of three dimensional images for a series of Generation of three dimensional images for a series of
two dimension Xrays taken around a single axis of two dimension Xrays taken around a single axis of rotationrotation
Computer generated images produce an axial imageComputer generated images produce an axial image Early CT scans in early 1970’s had single slice, Early CT scans in early 1970’s had single slice,
allowing imaging of the brain in four minutesallowing imaging of the brain in four minutes Modern state of the art scanners can have up to 200 Modern state of the art scanners can have up to 200
slices and can image the whole body in 30 secondsslices and can image the whole body in 30 seconds Iodine base contrast material in injected in an arm Iodine base contrast material in injected in an arm
vein to optimize visualization of vessels and solid vein to optimize visualization of vessels and solid organsorgans
Uses ionizing radiation to obtain images, and should Uses ionizing radiation to obtain images, and should be used with caution in pregnant or pediatric patientsbe used with caution in pregnant or pediatric patients
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CT cont.CT cont.
Advanced techniquesAdvanced techniques CT angiography and venography CT angiography and venography – Contrast rapidly injected into an arm vein and timed Contrast rapidly injected into an arm vein and timed
to visualize arteries and veinsto visualize arteries and veins– Has become first line minimally invasive procedure Has become first line minimally invasive procedure
to image the intracerebral vasculature and coronary to image the intracerebral vasculature and coronary arteriesarteries
CT perfusionCT perfusion– Rapid imaging of the brain after contrast injection Rapid imaging of the brain after contrast injection
followed by computer post processing can generated followed by computer post processing can generated area in the brain at risk for strokearea in the brain at risk for stroke
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Magnetic Resonance Magnetic Resonance Imaging (MRI)Imaging (MRI) Powerful magnetic field used to align hydrogen atoms Powerful magnetic field used to align hydrogen atoms
in the bodyin the body Radiowaves are activated that alter the alignment of Radiowaves are activated that alter the alignment of
this magnetization, allow for the atoms to relax at this magnetization, allow for the atoms to relax at different rates according to their chemical compositiondifferent rates according to their chemical composition
These signals are manipulated to reconstruct images These signals are manipulated to reconstruct images of the bodyof the body
Greater soft tissue contrast than CTGreater soft tissue contrast than CT No ionizing radiationNo ionizing radiation Must be extremely careful to remove all metal from Must be extremely careful to remove all metal from
patientspatients Contraindicated in patients with pacemakersContraindicated in patients with pacemakers
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MRI cont.MRI cont.
Advanced techniquesAdvanced techniques– MR AngiographyMR Angiography
detection of moving molecules done without detection of moving molecules done without the injection of contrast to visualize flowing the injection of contrast to visualize flowing bloodblood
excellent to visualize head and neck excellent to visualize head and neck vesselsvessels
– Gadolinium based contrast agent is injected Gadolinium based contrast agent is injected into an arm vein, mixed with flowing blood and into an arm vein, mixed with flowing blood and allows for visualization of vessels especially in allows for visualization of vessels especially in the chest and abdomenthe chest and abdomen
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MRI cont.MRI cont.
Diffusion imagingDiffusion imaging– For visualization of acute stroke, damaged For visualization of acute stroke, damaged
cells swell and cause restricted diffusioncells swell and cause restricted diffusion MR spectroscopyMR spectroscopy
– Separating the chemical composition of Separating the chemical composition of brain lesions into different peaks to brain lesions into different peaks to determine chemical compositiondetermine chemical composition
Functional MRIFunctional MRI– Using changes in blood flow to monitor Using changes in blood flow to monitor
neural activityneural activity
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NeuroimagingNeuroimaging
NonvascularNonvascular
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NeuroimagingNeuroimaging
VascularVascular
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Vascular diseasesVascular diseases
StrokeStrokeTrauma/Intracranial HemorrhageTrauma/Intracranial HemorrhageAneurysmAneurysmArteriovenous MalformationsArteriovenous Malformations
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StrokeStroke
Acute episode leading to a Acute episode leading to a neurologic deficitneurologic deficit– 80% are due to ischemia (either 80% are due to ischemia (either
thrombotic or embolic)thrombotic or embolic)– 20% other 20% other
Transient ischemic attack (TIA)Transient ischemic attack (TIA)– Focal events that resolve in 24hrsFocal events that resolve in 24hrs
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Stroke cont.Stroke cont.
Of the 80%, three quarters are due to Of the 80%, three quarters are due to atherosclerotic disease or occlusion of atherosclerotic disease or occlusion of vessels.vessels.
Diagnosis can be made by both CT and Diagnosis can be made by both CT and MRI, as well as the advanced images MRI, as well as the advanced images techniquestechniques– MRI is more sensitive, it can age strokes and MRI is more sensitive, it can age strokes and
can detect an acute stroke within thirty can detect an acute stroke within thirty minutes.minutes.
– CAT scan can detect a stroke within 6 hrs, and CAT scan can detect a stroke within 6 hrs, and is useful to determine if there is underlying is useful to determine if there is underlying hemorrhagehemorrhage
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71 year old white 71 year old white femalefemale
Found by husband in the bathroom on Found by husband in the bathroom on the floor, unable to move left side of her the floor, unable to move left side of her bodybody
Brought by EMS to AMH and had a CAT Brought by EMS to AMH and had a CAT scanscan
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Cont.Cont.
Admitted to intensive care Admitted to intensive care CAT scan performed 6 hrs later CAT scan performed 6 hrs later
after worsening of symptomsafter worsening of symptoms
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Cont.Cont.
Patient continues to deteriorate, Patient continues to deteriorate, despite supportive measuresdespite supportive measures
CAT scan performed 24 hrs after CAT scan performed 24 hrs after admissionadmission
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No improvementNo improvement CAT scan performed 12 hrs later, CAT scan performed 12 hrs later,
48 hrs after admission48 hrs after admission
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19 year old white male 19 year old white male
Found unconscious in dorm room Found unconscious in dorm room by roommate after drinking all by roommate after drinking all night at a fraternity partynight at a fraternity party
Friends had seen him take some Friends had seen him take some pills, found later to be valium pills, found later to be valium (benzodiazepine-tranquilizer)(benzodiazepine-tranquilizer)
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Anoxic brain injuryAnoxic brain injury
Lack of blood flow to the brain Lack of blood flow to the brain affects deep grey matter affects deep grey matter structures and can cause structures and can cause irreversible damageirreversible damage
Can also be seen in near Can also be seen in near drowning, carbon monoxide drowning, carbon monoxide poisoningpoisoning
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Intracranial Intracranial HemorrhageHemorrhage Non TraumaticNon Traumatic
– Hypertension (most common)Hypertension (most common)– TumorTumor– otherother
TraumaticTraumatic– Epidural and subdural HematomasEpidural and subdural Hematomas– Hemorrhagic contusionsHemorrhagic contusions
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Hemorrhage cont.Hemorrhage cont.
Hypertensive type most common Hypertensive type most common in small arteries off of the middle in small arteries off of the middle cerebral arterycerebral artery
High mortality depending on size High mortality depending on size and locationand location
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81 year old black male81 year old black male
Found at breakfast with difficulty Found at breakfast with difficulty speakingspeaking
Brought to AMH by sonBrought to AMH by son Ran out of blood pressure Ran out of blood pressure
medicine last weekmedicine last week Vital signs in ERVital signs in ER Blood pressure 210/80Blood pressure 210/80 CAT scan upon arrivalCAT scan upon arrival
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Cont.Cont.
ICU Staff was unable to control ICU Staff was unable to control blood pressure, symptoms blood pressure, symptoms worsenedworsened
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Hemorrhage cont.Hemorrhage cont.
TraumaticTraumatic– Subdural hematomasSubdural hematomas
Common in the elderly or in children Common in the elderly or in children due to child abusedue to child abuse
Tearing of bridging veins along the edge Tearing of bridging veins along the edge of the brainof the brain
Can grow large and may need Can grow large and may need neurosurgical evacuationneurosurgical evacuation
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Hemorrhage cont.Hemorrhage cont.
Epidural hematomaEpidural hematoma– Mostly due to injury to the middle Mostly due to injury to the middle
meningeal artery, superficial vessel meningeal artery, superficial vessel that runs along the skullthat runs along the skull
– Commonly associated with skull Commonly associated with skull fracturesfractures
– Large ones are neurosurgical Large ones are neurosurgical emergenciesemergencies
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AneurysmsAneurysms
Most common type is the berry or Most common type is the berry or saccular aneurysm saccular aneurysm – Are usually congenital or degenerative Are usually congenital or degenerative – Focal outpouching of a arteryFocal outpouching of a artery– Occur in specific locations along the Circle Occur in specific locations along the Circle
of Willisof Willis– Once diagnosed, the risk of rupture is Once diagnosed, the risk of rupture is
1.3% per year1.3% per year– A ruptured aneurysm requires urgent A ruptured aneurysm requires urgent
diagnosis and treatment, due to a high risk diagnosis and treatment, due to a high risk of rebleeding and 50% mortalityof rebleeding and 50% mortality
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Aneurysms cont.Aneurysms cont.
Patients present with “worst Patients present with “worst headache of life” and can have headache of life” and can have varying stages of consciousnessvarying stages of consciousness
CAT scan of the brain show CAT scan of the brain show diffuse subarachoid hemorrhage, diffuse subarachoid hemorrhage, “crab of death”“crab of death”
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Aneurysms cont.Aneurysms cont.
TreatmentTreatment Conventional-crainiotomy and Conventional-crainiotomy and
aneurysm clippinganeurysm clipping Neurointerventional-intravascular Neurointerventional-intravascular
coilingcoiling
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Arteriovenous Arteriovenous Malformations (AVM)Malformations (AVM) Network of arteries connected directly Network of arteries connected directly
to veins with no intervening brain to veins with no intervening brain tissue or capillariestissue or capillaries
Can hemorrhage because of high flow Can hemorrhage because of high flow statestate
TreatmentTreatment– Endovascular coilingEndovascular coiling– GlueGlue– Stereotactic RadiosurgeryStereotactic Radiosurgery
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58 year old female 58 year old female
MVA, crashed car into a tree MVA, crashed car into a tree because she “blacked out”because she “blacked out”
Arrives at AMH with headache, Arrives at AMH with headache, bruising but awakebruising but awake
CAT scan performedCAT scan performed
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Brain TumorsBrain Tumors
Primary brain tumors are 70% of Primary brain tumors are 70% of all intracranial neoplasmsall intracranial neoplasms
The remaining 30% represent The remaining 30% represent metastases from primary tumors metastases from primary tumors elsewhere in the body, common elsewhere in the body, common ones include lung and breast ones include lung and breast cancercancer
MRI with Gadolinium in the MRI with Gadolinium in the modality of choice for diagnosismodality of choice for diagnosis
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Brain tumors cont.Brain tumors cont.
Primary Brain TumorsPrimary Brain Tumors– 80% are gliomas, the most aggressive 80% are gliomas, the most aggressive
is the Gliomblastoma Multiforme (GBM)is the Gliomblastoma Multiforme (GBM)– 20% are all others, which include 20% are all others, which include
meningiomas from the brain surface, meningiomas from the brain surface, nerve sheath tumors and lymphomanerve sheath tumors and lymphoma
– Treatment is a combination of surgery, Treatment is a combination of surgery, radiation and chemotherapyradiation and chemotherapy
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Thank youThank you
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