_______________________________________________________________________________________________
NEURORADIOLOGY
CONGENITAL LESIONS
A- Craniosynostosis:- (Premature fusion of Skull Sutures)
1- Fusion of coronal & lambdoid Sutures oxycephaly = tower like which may be associated
with: -8 th C.N lesion
-optic nerve compression
-mental deficiency, syndactly
( usually shows prominat convolutional markings)
2-Premature fusion of sagittal suture
NB: In microcephaly : small head d.t. premature closure of all the sutures+ primary mental defect
3-unilateral premature closure of coronal&lambdoid suture
assymetrical skull =
triangular head
B- Lacunar Skull : - In infants , disappear by 4-6 months, ch.ch. . by groups of round, oval or
finger shaped pits of the inner surface of vault (membranous part) seperated by ridges of bone
They lie in thickest part of frontal, parietal & upper occipital bone commonly associated with CNS
anomalis
myelomeningiocele, hydrocephalus
** NOTES:
C- Cranial meningeocoele & encephalocoele:-Common in occipital and frontal region,usually diagnosed clinically , but difficult
in small lateral & basal meningeocele. Suspected if there is scalp swelling with underling bone
defects.
Encephalocele
hypertelorism
nasal obstruction
-C.T.: may show 3rd ventricle extend down through pitutary fossa into the sphenoid
Neuroradiology 1
_______________________________________________________________________________________________
empty sella
D- platybasia :A condition in which the base of skull appears relatively flattened . It include basilar
impression & basilar invagination.
*Basilar invagination:
-causes :- diseases producing bone softening( acquired)
{Pagets disease , Rickets , osteomalacia , ost. imperfecta & hyper parathyroidism}
*Basilar Impression:
Indicates an elevation of floor of the posterior fossa. commonly associated with
congenital anomalies of cervical spine . The foramen magnum may be abnormal in
shape and size.
***Lines & measurments of platybasia :1-Basal angle: A line drawn from nasion to tuberculum sellae in lateral view and a
second line drawn from tuberculum to ant. margin of the foramen magnum . This
measures between 125-142 . If > 142 , it indicate platyplasia.
2-Chamberlains line: from back of hard palate to posterior lip of the foramen
magnum in lateral view . Cd so if > odontiod peg lies above this line .
( see figure beside)
F-Hamartomas:
calcifications
Tuberous sclerosis(+bone,resp.,kid.&heart)
Neuroradiology 2
_______________________________________________________________________________________________
Sturge Weber
Ataxia Telangectasia
1 Nervous : Multiple area of heterotopia in the Brain ( area of abnormal glial tissue)
They contain calcification
widely scattered
small rounded discrete
may be paraventericular nodule near the foramen
2 Bone : skull
spine
pelvis
4 Kidney : show renal cysts as well as angiomyolipoma ( lesiones are multiple & bilateral)
1) Skull
Extensive calcfication of the choroid plexsus of the 3rd & lat ventricles
Abscense of greater wing of spheniod (bare orbit)
unilateral
exophthalmous
2) C.N.S
3) Spine
4) Kidney
Neuroradiology 3
_______________________________________________________________________________________________
5)Skeletal
- cerebral edema
.
(4) Craniosynostosis
(5) Benigin Intra-cranial hypertension
Radiological Evidence of I.C.P :
No radiololgical evidence of I.C.P. seen before 6 weeks of the condition
* Effect of I.C.P :
(1) effect on sutures (chidren)
Neuroradiology 4
_______________________________________________________________________________________________
Infants & children= suture diastasis ,coronal & saggital are the most affected
- As condition become chronic
abnormalities of the sella + central part of the anterior fossa(cribriform plate) may be
displaced down in the lateral films
NB : increased vascularity (generalized or localized) = dilated emissary veins above int . occipital
protuberance also occurs in older children with chronic ICT
Erosion commences as slight porosis of the anterior cortex of the dorsum & of the sellar
floor cortex (best seen in lateral films). It progresses to loss of definition of the cortex
also towards the Lamina dura- & eventually to frank erosion
* Sellar enlargement :
may accompany later stage of erosion, its type differes from that due to pitutary
tumors balloning & flattening (see figure beside )
C) Bones of vault :
* Infancy & childhood
- when I.C.P. occurs in ante nal peroid, the bone of skull vault become :
I- thinner than normal
.
frontal & parietal bones. NO convolutional impressions over the lower 2 / 3 are of
diagnotic value ,as they represent bone growth in response to underlying brain.
NB : convolutional markings are of diagnostic value only if in the upper 1/ 2
*Adult
- When the cause of
of calvaria .
- long standing hydrocephalus
Neuroradiology 5
_______________________________________________________________________________________________
Neuroradiology 6
_______________________________________________________________________________________________
5-10 % of gliomas
50% - 90% of oligodend roglioma
20% of posterior fossa glioma
rarel in medulloblastoma & malig. Astrocytoma
- Forms
curvilinear calcification
Neuroradiology 7
_______________________________________________________________________________________________
post. fossa
* adults
supratentorial
.
II. Vascular Lesions :
(1) Aneurysms :-Incidence: less than 1%
Neuroradiology 8
_______________________________________________________________________________________________
small flecks
Phakomatosis
Lipoma
Neuroradiology 9
_______________________________________________________________________________________________
2- Intracranial tumors
- pituitary adenoma, craniopharyngioma , optic glioma , meningiomas ,rarely gliomas
- osteomyelitis , TB , fibrous dysplasias
(i.e. infections, metabolic, neoplastic & dysplasia)
* Hyperostasis :1-Generalized
- marble bone disease
- Englmans disease
-craniometaphyseal dysplasia
- acromegally
- pagets disease
- thalassemia
2-Localized
-meningiomas
-osteomas
-ossifying fibroma
-fibrous dysplasia
-leontiasis ossia
-hyperostosis frontalis interna ( unknown cause postmenopausal + )
-sclerosing metastases
-chronic osteomyelitis
*Sturge -Weber- Dimitri Syndrome :=encephalo -trigeminal angiomatosis
=vascular malformation with capillary venous angiomas due to persistence of usually
transitory plexus stage of vessel development (developmental neuro-ectodermal
dysplasia of unknown etiology involving skin-CNS-eye)
-Clinical picture :
Seizures(90%)
Facial port-wine stain along sensory branch of trigemial
Mental deficiency (50%)
Crossed hemiparesis
-Radiological findings :
(1) Plain films
A.Tram line calcification(i.e. along vessels )
-site ; in occipital bone(cortex) in the surface of atrophic branches of trigeminal
B. thickened meninges
C. ipsilateral thinning of the skull & orbit (reaction to brain atrophy)
Neuroradiology 10
_______________________________________________________________________________________________
asymmetry of lobes
2.Late
- Infectian : abscess
- Infarctian : atroply , porencephally
- Cephalhaematoma
- Leptomeningeal cyst
- Hydro cephalus
- Cortico cavernous fistula & sersiod anuerym
-
Calcification
N.B. for any hemorrhage mention :
(shape
Neuroradiology 11
_______________________________________________________________________________________________
Head Injuries.
* Diagnostic methods:(1) plain x-ray : lateral, lateral with horizontal ray, O. F., base, towens
(2) C.T.
(3) Angiography
(4) U/s : through anterior fontanellae in infants
(5) MRI
* Radiological manifestations (plain film) :A. Displacement of calcified pineal body
-may occur with the presence of intra cranial haematoma
confirmed by CT
B.Fractures
1- Linear fractures of vault:- may carry possibility of an extradural haematoma
Appearance:
- It shows as black line & have sharp edges .
- line crosses vascular markings
- If it diverted into a suture
-less translucent
*Tangential
if area is large
if area is small
Neuroradiology 12
_______________________________________________________________________________________________
4- Fractures of facial bones:5- Foreign bodies:-more than view may be necessary to confirm the diagnosis other wise C.T. is
recommended
NOTES :
-pneumocephalus & aeroceles result from fractures involving frontal or ethmoid sinuses
-obtained by views with head brow up & horizontal x-ray beam to demonestrate possible air
fluid levels
-this view is also uesful to detect air fluid level in sphenoid sinus which indicates fracture in
the skull base
* Late effects of head injury :(1) Calcification in subdural & extradural haematomas :Sub-dural It appears as an incomplete shell conforming to the general shape of the
collection.
Extra-dural
Neuroradiology 13
_______________________________________________________________________________________________
dural tearing escape of C.S.F. from subarachnoid space a very large swelling
of tissues of scalp which become distended by C.S.F (atrophy of overlying bone
margins may occur & large bone defect may follow )
-after a few weeks the fracture line begins to widen by thining & erosion of bone
& large bone defect may be seen
-clinically there is a superficial cystic mass
-radiologically there is elongated area of lusency with or without a fracture
extending into it
* C.T. in cranial trauma :Indications
1-deterioration in patients condition
2-suggestion of an expanding intracranial haematoma
Complications of trauma
A) Acute : (1) Intracranial haemorrahge or haematoma extracerebral,
extra-dural, subdural, subarachnoid, intracerebral
(2) cerebral edema & contusion
(3) fractures
(4) F.B.
NB ; CSF otorrhoea or rhinorrhoea both need
CT cisternography
Radio nuclide scanning
=fracture in petrous
or mastoid bone
B) Late :-
=fracture in the
skull base
(+ post traumatic sequaele )
(3) Miscellaneous
Neuroradiology 14
_______________________________________________________________________________________________
c) enhancement
no
d) others
-origin : usually arterial bleeding from meningeal vessels (serious)
-site: most commonly in tempro parietal region & tend to be localised
-associated skull fractures
* Subdural :- ( Its appearance depend upon the stage)
a) Acute subdural hge.(first 48 hrs)
1.
3 . enhancement
no
4 . others
-origin : more commonly of venous origin but may be arterial
arising from a tear of vein bridging subdural space
-small lesion : less than 1cm may not be detected , so detection may be
increased by tilting head to affected side
b) Subacute hge (2 - 4 weeks)
1. attenuation & edema isodense , if there is evidence of a capsule a line of
high attenuation is seen along its medial border
2 . mass effect
3 . enhancement
4 . others
* Bilateral isodense hge ( difficult diagnosis, the clue may be ) :
-ventricular assymety ; as the lesions are not of same size in both sides
-lack of normal wider sulci in older patients
-the frontal horns lie more closer together > normal
(termed
c) Chronic subdural hge ( > 4 weeks )
1. Attenuation & edema
Neuroradiology 15
_______________________________________________________________________________________________
3. enhancement
N.B. contrast causes brain enhancement & lesion is seen against enhanced brain
4. others
attenuation posteriorly as the patient is lying supine with low attenuation anterior to it
* Subarachnoid :1. attenuation & edema
no
3. enhancement
no
4 . Others
+Associated
traumatic lesion
areas of infarction due to arterial spasm
hydrocephalus due to blood in subarachnoid space
1. attenuation & edema multifocal hyperdense lesions & may be surrounded by areas of low
attenuation ( dueto blood clots & damage of blood brain barrier) 50-90 H.F. (+ associated low
denisty areas of perifocal -little- edema with brain swelling )
2. mass effect
3. enhancement
little
no, but may occur after weeks around a clot due to damage
to B.B.B & new vascularity develops
4. others
- classical sites
Neuroradiology 16
_______________________________________________________________________________________________
* Intraventricular :-usually accompanies other traumatic haematomas & appear as high attenuation
inside the ventricles
NB : Value of CT is to detect
-attenuation
mass lesion of mixed attenuation (high & low) predominantly hypodense
usually multifocal (he occuring 24 hrs or later )
at first hours after injury , attenuation usually hypodense with mass effect
but later , there may be multiple he with high attenuation
B- Simple (non hgic) contusion
-attenuation
-mass effect
occurs
accurate localisation
Neuroradiology 17
_______________________________________________________________________________________________
-Appearance
similar to those dt. thr-embolic lesions but usually involve frontal lb.
-Attenuation
region of low density (10-30 H.U.) at first ill defined , but by the
second week , it becomes well demarcated
-Mass effect
-Edema
-Enhancement
-Shape
focol (common)
Generalised (diffuse)
Cause
C.T. criteria
-enlargement of fissures & sulci
-dilated ventricles
-associated porencephalic cyst
* Porencephalic cyst :-it is due to degeneration of damaged portion of the brain
-it usually communicates with ventricular system
-of low attenuation value (=C.S.F.)
-MRI appear as signal void rounded area at the site of anatomical vessel & after i.v.
gadolenium the lumen of vessel doesnt enhance since rapid flow of blood prevent the
effect of contrast (this is very important & characterestic )
* Hydrocephalus :-incidence
-CT appearance
1. earliest sign is dilatation of temporal horns
-differential diagnosis
2. ventricular dilatation
brain atrophy
as before (fracture
dural tear
CSF leak
-C.T. appearance
1.underlying brain damage
2.expansion of subjacent portion of ventricular system
swelling)
Neuroradiology 18
_______________________________________________________________________________________________
Neuroradiology 19
_______________________________________________________________________________________________
Hyperacute
Acute
Hemoglobin type
Magnetism
MR appearance
T1w
T2w
< 24 hrs
Oxyhemoglobin
Diamagnetic
T1w = T2w
black
Black
1-3 days
Deoxyhemoglobin
Paramagnetic 4
Intermediate black
Very black
unpaired electrons,
Surrounding edema
however it cause
no shortening
Early
subacute
4 -7 days
Late
subacute
2wks to
8 months
Methemoglobin
Paramagnetic 5
(intracellular)
unpaired electrons
center
center
central deoxyhg
Methemoglobin
Paramagnetic 5
(extracellular so only
unpaired electrons
causing changes in
center
center
T2W images)
Chronic, rim
+ 14 days
Hemosiderin
Diamagnetic
(> 8 mth)
Macrophages e
Outside black
Outside black
hemosiderin =
Chronic,
Central
+ 14 days
Hemichromes
Diamagnetic
surrounding white
(>8 mth)
subacute
MRI of cerebral contusion :1) T1 region of poor grey / white matter discrimination
2) T2 ill defined areas of hyperintensty
3) cisterna around brain stem is obliterated
Neuroradiology 20
_______________________________________________________________________________________________
MRI of subdural haematoma :-MRI is superior in demonestration of extracerebral collection although initially it may
be isointense with adjacent brain
1.the lateral margin is well seen unobscured by bone
2.the displaced cortex is clearly evident
3.the adjacent mass effect is well shown than CT
4.the collection becomes progressively more hyperintense on T1
VASCULAR LESIONS
aneurysms
arterio-venous
arterio-venous
malformations
fistula
embolus-stenosis
& thrombosis
CT appearance:
1. Density:
Recent hge: rounded high density lesions with smooth margins. Enlarging size in successive scans
denote active bleeding.
Old haematoma: gradual diminution in density isodense and can be detected only by mass effect.
Weeks later: a denser pre-contrast ring may locate the margin of a organizing haematoma.
2. I.V Contrast: enhancement: in acute recent Hge no need for C.M.
Ring enhancement may be seen around resolving haematoma, DD from tumors or abscess.
3. Mass effect: is attributed directly to size & location of lesion.
4. Location: 20% of hypertensive haematomas occur in the supratentorial compartment putamen,
thalamus, head of caudate N. and external capsule. In posterior fossa, the pons and cerebellar
hemispheres are other usual sites of hge.
Ventricular and subarachnoid extension:
Capsular or thalamic hematomas may dissect medially and rupture into ventricular system or into
the Sylvian fissure subarachnoid spaces
2-Aneurysms:
-Sites of aneurysms:(around circle of Willis: 75%)
1. Posterior communicating artery (27% )
2. Junction of anterior communicating with anterior cerebral (27% )
Neuroradiology 21
_______________________________________________________________________________________________
Subarchnoid hge:
- Plain: ring calcification (late)
- CT is the 1st choise for large aneurysms (> 1cm) shown as high density rounded lesions at base
of brain, enhance immediatly & strongly after contrast (may be thrombosed: isodence center) +
marginal calcifications & d.d.: Suprasellar mass (meningioma, carniopharyngioma, pitutary
tumor) or large basilar aneurysms (clivus chordoma or meningioma).
-MRI shows area of signal void (residual lumen) along course of named arteries close to the circle
of Willis, if large clear extra axial mass + surrounded by areas of variable signal clot. Mri
helps in dd aneurysm from tumors and meningioma.
-Angiography:
1-
To find aneurysms smaller than 5mm in diameter (only detected by angiography) may
require
Injection of both internal carotid & may need vertebral with AP, lateral & oblique transorbital
(also Towens for vertebral
2 -Following recent bleeding, vessels in the region of the rupture of aneurysm is in spastic &
narrow state ischamic effect (spasm localasition).
2-
Localise aneurysms neck, they are always multiple and 5-15%, largest one almost bleeds &
this
if severe intracranial haematoma displacement of vessels, mass effect & stretch of vessels
B. Pressure upon cranial nerves leading to orbit:
-Commonest nerve is 3rd , but 4th 5th & 6th may be involved
-This is usually caused by aneurysm intracavernous sinus or affecting the PCA
- Occasi.ly suprasellar aneurysm may involve optic chiasma or optic nerve
C. Large mass: either supratentorial (rare) or infratentorial
-They simulate an intracranial tumor
1.basilar rare & simulate tumor & vertebral angioma
2.large aneurysm of internal carotid bulgs forward in the orbit, erode sphenoidal fissure &
cause proptosis ( d.d. 2ry deposits meningioma )
3.area of vein of galen in infants & children seizures, hydrocephalus & it
shows calcifications at the wall
3-Angiomatous malformations: (cause: congenital AVF but present in adults of 20-40 yrs)
-Definition
Neuroradiology 22
_______________________________________________________________________________________________
cavernous angioma
venous angioma
capillary taelangectasia
spinal angioma
-Pathology
communication between the artery & vein lies over the surface of
brain but , if large they extent down in the brain substance in a manner of inverted cone
in shunt area It is symptomless but in motor cortex or occiptal cortex
Jaksonian epilepsy or cortical field defect + headache which is migranous in nature &
also may rupture subarachnoid haemorrahge
-Radiological findings
A.
heamatoma
displacement of vessels
mass effect
stretched vessels
B. CT:
1.Serpigenous, serpentine high density shadow (thrombosed enlarged vessel)
2.Calcification
4-
Neuroradiology 23
_______________________________________________________________________________________________
dura , orbit or scalp. Dural AVF are malformation between meningeal branches of ECA & ICA
and dural veins near cavernous sinus (= dural shunts resulting in increase IOP & proptosis).
- Intra cranial (rare):
1- Drain by superior opthalmic vein, superior pertrosal sinus & basal vein
2- Seen in cavernous sinus (cortico-cavernous fistula )
Mass effect: small superficial early infarcts may be identified by sulcal obliteration, larger infarcts
may show some degree of mass effect for even a month.
Location: ACA- MCA- PCA
MRI :
- Infarcts commonly seen more extensive than on CT. T1 & T2 are prolonged in infarcted &
severely ischemic tissue.
- MRI + Gd enhancement towards the end of the 1st week.
- Occluded artery signal void.
- MRI may be less sensitive than CT at detecting areas of hemorrhage within the first few days.
Scheme for Brain Tumors:
1-Def origin
2-Incidence
3-Age
4-Pathology and sites
Neuroradiology 24
_______________________________________________________________________________________________
5-Clinical picture (increased ICT, Hormonal effects)
6-Radiological appearance:
-PXR: Calcification, displacement of pineal body, increased ICT, abnormal vascular
markings, erosions or hyperostosis.
-CT:
Attenuation before contrast, enhancement after + Odema, necrosis, hge + Calcification
Mass effect (mid line shift ventricular compresion - hydrocephalus)
-MRI: Low on T1, high signal on T2, enhance after Gd-EDTA
-Angio: vessel diplacement, pathological vessels.
7-Complications: increased ICT, hydrocephalus, hge, lateralization
Brain Tumors
A. Supratentorial tumors :1. Gliomas
astrocytomas
(30% )
oligo-dendroglioma
ganglioglioma
calcification
3rd ventricle ( bengin)
optic
2. Secondary deposits
metastasis
(20% )
3. Sellar tumors
lymphoma , leukaemia
see later
see later
5. Neuroblostoma
6. Tumors in & adjacent to 3rd ventricle
colloid cysts
germinos = pineloma
teratomas
pineoblastomas
pineocytomas
dermoid
teratoma
lipoma
colloid cyst
choroid plexsus papilloma
ependymoma
9. Meningioma
B. Infratentorial Tumors :1. Intracrainal
brain stem
cerebellum
glioma
secondaries
primary
astrocytoma
medulloblastoma
hemangioma, ependymoma
2. Extracranial
Neuroradiology 25
_______________________________________________________________________________________________
5-15years
15-30years
Ependymoma
30-65years
> 65 years
-PXR
-angiography
-CT
enhance (general)
pathological vessels
-pathology
-site
-CT picture
1.attenuation poorly marginated, non homogenous, low attenuation area
merging with the surrounding cerebral parenchyma (cystic glioma is well
defined area of low attenuation )
2.edema little or no (edema affects white matter rather than grey & often
extends with finger-like processes subcortically & into corpus callosum,
external & internal capsules)
3.contrast enhancement no (so it is not possible to differentiate between it and
Neuroradiology 26
_______________________________________________________________________________________________
4.calcifications
uncommon.
uncommon
- Differential diagnosis
1.similarity
2.difference
-pathology
lateral hemisphere
butterfly glioma
2.edema
4.mass effect
when large
5.calcifciations
no
carcinomatous metastasis
pyogenic cerebral abscess
*Oligodendrogliomas :-incidence
5%
30-40%
Neuroradiology 27
_______________________________________________________________________________________________
-pathology
-CT :
1.attenuation
2.edema
no
3.enhancement
4.calcifications
5.mass effect
6.haemorrahge
no
7.cystic degeneration
in large tumor
*Gangliogliomas :-incidence
-pathology
temporal lobe
-CT
1.attenuation
2.edema
3.enhancement
4.calcifications
5.mass effect
6.haemorrahge
as above
1% (childhood )
from optic nerve or chiasma
low grade astrocytoma infilterating along the fibre tracts & nerves
typically involve intracranial & orbital portion of optic nerve
usually associated with neurofibromatosis
-CT
1.enlargement of the optic canal
2.enlargement of intraorbital & inrtracranial portions of optic nerve(enlargement
Neuroradiology 28
_______________________________________________________________________________________________
is usually diffuse & uniform, occasionally enlargement may be irregular and fusiform )
variable
no
calcification
no
obstr. of 3rd ventricle
-differential diagnosis
1.optic nerve sheath meningioma (old age, fusiform, calcified, tram-track )
2.optic nerve neuritis
(NB: charchterestics are child, tubular, diffuse enhancement)
*Secondary deposits :* Metastatic brain deposits :(The brain is common site of haematogenous metastasis from
bronchial
lining of ventricles
parenchymal neoplasm
1.attenuation
2.edema
3.contrast enhancement
4.mass effect
mass effect
universal, intense(v.imp.)
++
Neuroradiology 29
_______________________________________________________________________________________________
B) Large
-central necrosis
Large metastasis
Glioblastoma
regular-spherical
irregular
homogenous
non homogenous
NB
bone sarcoma
colon cancer
2.epidural
3.leptomeningeal
-thick, sheet like, homogenous contrast enhancement obliterating major intracranial subarachnoid cisterns is diagnostic (simulate picture of gross subarachnoid
haemorrahge in non contrast films)
-nodular, homogenous enhancing masses may be seen in quadrigeminal and pineal
region
4.ependymal and subependymal
-tumor spreads in the wall of ventricles sheet like or nodular plaque
like intense contrast enhancement
- differential diagnosis from ependymits, complicating rupture of cerebral
abscess
Lymphoma & leukaemia :-old name is microglioma (1ry is more common than 2ry)
-in both leptomeningeal infiltrations of meninges by tumor cells occur firstly and then
spread along the space of Virschow to penetrate the brain
-They are similar to metastasis but
less or no edema
central necrosis is not a feature
Neuroradiology 30
_______________________________________________________________________________________________
Meningioma:
- It is commonest benign intracranial tumors but can turn malignant usually vascular angioblastic
type (others are fibroblastic & calcified types) - recurrence after surgery is not uncommon
- Multiple in 5% in association with neurofibromatosis
Types of meningiomas:
a)Sellar
b)Supra-sellar ( infratentorial )
c)Cerebello-pontine angle
d)Intra-orbital w can be either:
-Primary: - extra-dural meningioma (within orbital cavity away from optic nerve)
- optic nerve sheeth meningioma foraminal, intra-canalicular, intra orbital.
-Secondary: orbital extension of meningioma arising at greater wing of sphenoid or
supra-sellar or floor of anterior cranial fossa
e)Spinal meningioma: extradural extramedullary - intradural extramedullary
Sites: - Most common: para-sagital, convexity, falcine
- Strategic sites: intraorbital, supra-sellar, diaph sella, CPA & cerebellar convexity
- Others: sphenoid ridge, pterion, tentorium, olfactory groove, spinal, intraventricular
DD of meningoma: optic nerve glioma neurofibroma - acoustic neuroma
meningioma differ from acoustic neuroma in that meningioma is larger than neuroma with broad base on the petrous, by
CT It is hyperdense homogenous intense enhancement + normal internal auditory meatus, hyperostosis +calcifications &
cystic changes. By angiography shows dense homogenous blush.
Radiological appearance:
Plain X-ray:
Occipito-frontal view: signs of ICP, intra-cranial calcification (ball like 20%
amorphus) - intra-cranial erosion - hyperostosis affecting apex of
orbit & ant. clenoid process (in primary orbital meningioma)
pineal displacement & hydrocephalus
Lateral view
Neuroradiology 31
_______________________________________________________________________________________________
hair-on end skull vault only when it breaks through outer table(ch.ch.)
orbital calcifications (1ry orbital meningioma)
Base
Optic
CT appearance:
-On unenhanced scan meningioma usually appear as homogenous intense high density mass
with rounded well defined margins
-Calcifications are found in 16-20% of cases (either irregular or uniform calcifications)
-Marked & uniform enhancement post C.M., heterogenous if large: central dots of necrosis
-Absent or minimal edema with or withiut cystic changes & mass effect in 10%
Angiography:
-Carotid angiography (selective external carotid DSA) it is of little role except when tumor
is adjacent to saggittal or other major sinuses w are well shown by intravenous DSA
-Ccc angiographic features are: ( presurgical embolization may be done)
hypertrophy of meningeal artery supplying tumor
hypertrophy of branches of external carotid supplying tumor
localization of the tumor in its characteristic sites
invasion of the arterial wall evidenced by cuffing or narrowing
the presence of typical meningoma blush + the above features
(blush peripherally supplied by anterior & middle cerebral arteries = internal carotid artery)
2072
-Pineal tumors = pinealomas = any tumor in pineal region part of PNET (primar neuroectodermal
tumors w also include dysgerminomas & medulloblastoma)
1.Pineal cell tumors: pineoloblastoma - pineocytoma
2.Glial tumors: astrocytoma glioblastoma
3.Germ cell tm: germinoma (pineloma)- teratoma - embryonal cell tumor - choriocarcinoma
4.Epidermoid dermoid metastases (v.rare)
- Age: 2nd & 3rd decades
Neuroradiology 32
_______________________________________________________________________________________________
- Highly malignant similar to testicular seminomas, most common is near 3rd third ventricle, in
pineal region is ectopic pineloma arising from floor of 3rd ventricle indenting back end of 3rd
ventricle obstructing aqueduct (suprasellar type) (this is how small tumors are detected )
- CT: spherical, hyperdense, sharply defined mass (solid-cystic-mixed) e homogenous intense
enhancement, no edema + may displace calcified pineal body & obstruct aqueduct leading to
hydrocephalus. Calcification are unusual.
Neuroradiology 33
_______________________________________________________________________________________________
-Hypothalamus
-CT: hypodense (-50 to -150 HU) sharply defined irregular mass, non-enhancing, no edema, linear
calcification are frequently seen.
Rathkes cleft tumor: suprasellar, benign, uniocular cyst, dd: craniopharyngioma
Pituitary tumors
- Pituitary gland, beam like structure e concave upper border (depth: 1.4 cm - AP: 1.6 cm height < 0.8cm) only
occupies posterior of sella turcica while ant. part of sella is filled with CSF.
- Pituitary gland is connected to hypothalamus via infundibular (at anterior surface of pituitary, near posterior clinoid
process) stalk w should be in midline (not seen until its end d.t. traversing optic chiasma).
- Above pituitary: is diaphragma sellae above w is suprasellar cystern containing circuit of Willis & above is anterior part
of 3rd ventricle.
- A depression post. to cavernous sinus is called "Rickle's cave" containing ganglion of trigeminal seen in post. cuts.
- MR protocol include: sagittal T1, sagittal T1+Gd-EDTA, coronal T1, axial T2, pituitary gland is of intermediate
signal in T1 & T2 but post. lobe is usually > white in T1 d.t. its higher fat content, pituitary stalk appears homogenous
enhancing as for normal pituitary tissue. ICA appears signal void while cavernous sinus enhances post contrast d.t. its
sluggish circulation. Sphenoid sinus (normally black in T1 & T2 d.t. air content) appears white if filled e fluid.
- T1W could be enough e no need for T2W i.e. all images enhance except for AVM & aneurysms.
Neuroradiology 34
_______________________________________________________________________________________________
- Specific signs: sellar deformity, enlargement, compression, acromegally, special skull changes,
hormonal effects, effect on optic chiasma.
Intrasellar lesions:
1-Pituitary adenomas 2080-81
1- Macroadenomas (non-functioning) >1cm
- Was previously termed the chromophobe adenoma
- It attains large sizes, grows slowly, presents late by signs of increased ICT + visual
disturbances (bitemporal hemianopia) + pan hypopituitarism.
- Called invasive adenoma if extending supra & infra + cavernous sinus.
2- Microadenomas (functioning adenomas) <1cm
a- Acidophil adenoma:
- Increase growth hormone: acromegaly in the mature & gigantism in adolescents.
b- Basophil adenoma:
1- Is usually a microadenoma with no sellar enlargement
Neuroradiology 35
_______________________________________________________________________________________________
Radiologically:
- PXR: increased sellar size acromegaly features cushing - increased ICT.
- CT: - Macroadenomas: -Isodense mass, extending to the suprasellar cistern, it shows areas of
necrosis or calcification
-Best way to see bony extention & erosion.
-Cavernous sinus invasion in parasellar extension (as can't be removed surgically)
- Microadenomas: small hypodense area in the pituitary gland, height > 8mm, contralateral
displacement of pituitary stalk and a convex upper border of pituitary gland.
(normally in young females upper pituitary gland is convex = hyperplasia)
- MRI:
1- T1-Gd EDTA: homogenous small adenoma or heterogenous large adenoma e central necrosis.
2- Only way to diagnose invasion of optic chiasma (stretched or absent CSF space)
3- Dilated lat. ventricles = suprasellar compressing optic chiasma & ant.part of 3rd V(F. Monroe)
4- Cavernous sinus invasion e signal void ICA, w should be symmetrical on both sides
5- ICA weither invaded or not, narrowed or occluded.
- Angiography: elevation of the transverse portion of the anterior cerebral Ar. in P.A.
2-Pituitary apoplexy
Def: hemorrhage inside a normal gland or in a pituitary tumor.
C/O: increase ICT + blurring of vision, usually presents in subacute phase because vague symptoms
CT: best seen by MR as subacute blood is seen in CT isointense
MRI: white in T1 & T2 in subacute stage (be sure it is not a contrast image) to be dd from dermoid
cyst via T2 images in w dermoid is black d.t. its fat content.
Neuroradiology 36
_______________________________________________________________________________________________
2-CT: is diagnostic as the pituitary gland is seen depressed with herniation of the suprasellar cistern
downwards + pituitary stalk dipping below level of posterior clinoid process.
3-MRI:
a) Coronal cuts (best): infundibulum is seen traversing the CFS-filled sella, to be inserted
into posteriorly displaced pituitary.
b) Axial T2: white area filling sella (CSF filling it)
DD: intrasellar arachnoid cyst
Parasellar lesions:
1-Meningioma:
- Homogenous enhancing parasellar lesion ccc by bone sclerosis (osteoblastic activity)
- Passes along meningeal reflections (tentorium & petrous apex) causing typical dural tail.
2-Neuroma:
- Homogenous enhancing parasellar lesion ccc by bone erosion + cl/p of fascial neuritis.
- Lesion passes along nerve from infratentorial origin in pons to prepontine cysterns & up to
parasellar region.
Suprasellar lesions:
1- Craniopharyngioma 2082 (w)
- Age (2 peaks): children: 5-15 yrs & adults: 60-70 yrs.
Neuroradiology 37
_______________________________________________________________________________________________
2-Meningiomas:
- Adult females, it arises from diaphragma sella & ccc by homogenous midline suprasellar
enhancement + lobulated surface & may calcify.
- Occurs in children (rare) in association of NF-II w is associated e gliomas & neuromas
- In early cases not surrounded by edema as suprasellar cystern is a wide space between it & brain.
3-Gliomas:
- Homogenous !! enhancing lesion e lobulated surface affecting pituitary stalk, hypothalamus or
optic chiasma or all of them.
- If it extends along pituitary stalk & make it thick it will have ccc figure of 8 appearance.
4-Aneurysm:
- From vessels of suprasellar cystern, perfectly rounded homogenously enhancing lesions
- Off midline as arise from vascular junctions, may be bilateral, +/-marginal calcification.
5-Sarcoidosis:
- Suprasellar lesion that can affect pituitary stalk or optic chiasma
- Midline, non-lobulated lesion in a middle age pt., +ve chest x-ray & +ve systemic symptoms.
Neuroradiology 38
_______________________________________________________________________________________________
Def: sellar floor is normally composed of a single dense line but sometimes 2 lines are seen.
- It is usually an abnormal finding, frequently seen in intrasellar tumors particularly adenomas.
Normal causes of a double sellar floor (pseudo-double):
1- Central depression in the floor of the sella
2- Asymmetric development of the sellar floor
3- Uneven development of the sphenoid sinuses
4- Groove for cavernous sinus and its ICA (carotid groove)
5- Incorrect patient positioning (not true lateral).
2-
3-
4-
5-
b)
Extra-axial:- Meningioma
-Aneurysm, AVM
- Lesions +/- eroding petrous bone as cholesteatoma & glomus tumor w arise from
chemoreceptor cells in jugular bulb (glomus jugular, carotid body tumor, glomus
vagale, tympanic tumor)
- Pearly tumours: epidermoid & dermoid ccc by keratin, fat, cholesterol content so
low density non-enhancing e CT, very low signal T1 & high T2 +/- flui dlevel
- Acoustic neuroma (50%) 72, 104, 2088, 2277
- Female > male 2:1
- Origin: neurilemma of acoustic nerve = vestibular
shwanoma (rarely the trigeminal), it grows by expansion.
- Site: CPA + internal auditory canal, unilateral and
bilateral with NF-II
- Clinically: decreased hearing dizziness headache
increased ICT.
Radiologically:
- PXR: widenning of int. auditory canal > 2mm, erosion of tip of petrous pyramid
(Stenver's-Town )
- CT:
Isodense mass, compression with
displacement of 4th ventricle
Hydrocephalus displaces brain stem to other side
Unilateral enlargement of internal auditory canal.
- CT with CM: well defined, markedly enhancing , homogenous at the posterior
surface of petrous pyramid.
- Angio: post-inf. Displacement of anterior inferior cerebellar artery.
- MRI:
- Intermediate signal on T1 e high signal on T2W contrasted against
lower signal of CSF - Gd-edta for small intracanalicular extension
(not done if seen in non-CM images)
To d.d. intra from extraaxial lesions:
Neuroradiology 39
_______________________________________________________________________________________________
1-
Extra axial lesions compress brain parenchyma keeping pontine and ambiant cyterns wide
compared to other side.
2-
Extra axial lesions extending in petrous bone are eroding (intra axial aren't)
3-
AVM will show serpiginous enhancement will epidermoid cyst will not.
4-
Lesions ccc:
- Meningioma's dural base + don't enters IAC but can scallope it if sizable.
- Intracanalicular (IAC) extention of neuroma along 8th
nerve course, center of the lesion corresponds to it
(not in meningioma) + history of SNHL + best is thin
cuts MRI over petrous: intermediate signal in T1 &
T2. (in past CT ventrilography was used)
a)
b)
c)
d)
e)
Lymphoma: not common but possible in association with other body lesions
f)
g)
Glioma: (usually missed d.t. interpetrous artifact, it flattens 4th V. anteriorly {dd lacunar
infarct}
h)
i)
Abcess: usually related to ear infection (post op.) + marginal uniform ring enhancement
j)
a)
Haemorrage: 2nd most common site for CVS after tempro-parietal region
b)
c)
d)
Neuroradiology 40
_______________________________________________________________________________________________
e)
k)
Abcess: usually related to ear infection (post op.) + marginal uniform ring enhancement
l)
- Diff. Diagnosis : Epidermoid cyst w is not limited (as astrocytoma) to infratentorial region
Dandy Walker Arachnoid cyt
n) Haemangioblastoma: 2075
- Age: 35 45 yrs it is solitary or multiple, mostly in posterior fossa.
- Pathology: vascular tumors but may develop large cysts w can mask underlying vascular nodule
- Radiologically:
1- CT: - solitary nodule with large cyst (can be mistaken for glioma or gliomatus cyst)
-mural nodule is identified in post enhancement scan (tumor nodule is isodense or slightly
hyperdense & enhances strongly after contrast media)
- multiple tumors are very small & may be easily missed
2- MRI : cyst & nodule are well demonstrated on T1, it causes homogenous low signal. Nodule is
low in T1 & T2 (may need Gd-EDTA), large vessels are frequently seen adjacent to tumor
3- Angiography: highly vascular, dense & early blush of contrast commencing at arterial &
continuing at venous phase - They may show A-V malformations (commonly AV
shunting) - vertebral angiography is indicated in every case since it is accurate
method to demonstrate multiple small lesions (which are missed on CT & MRI)
NB: In Von Hippel Lindau $: may show multiple hemangioblastoma of cerebelum, retina sp.cord.
b)
Ependymoma: 2075 (in young 15 yrs: 4th V. adult: lat V.+ cerebrum) "it is a type of
glioma"
- CT: -Hyperdense homogenous lesion w markdly enhance & causes hydrocephalus via
obstrution of 4th V.
-Can calcifie w is ccc in 30 % & spread via seeding (or serosal) through CSF to cysterns
causing another enhancing area in CSF on the surface of the brain & basal cysterns.
- MRI: low T1 and high T2
Neuroradiology 41
_______________________________________________________________________________________________
c) Medulloblastoma: 2074
- Age: child < 5 yrs male neuronal in origin (primary neuroectodermal tumor = PNET)
- Ccc: -Midline, malign. tm from roof of 4th V. and grows inside it & rarely arise in adult from
cerebellar hemisphere & not from vermix.
-Invades brain stem & obliterates 4th ventricle so hydrocephalus is common & metastasy
via CSF into cerebrum ( do a brain MRI)
-Calcification in medulloblastoma occurs in 13% of cases.
- Radiologically: heterogenous enhancement, ident ventricle, e minimal perifocal edema
c)
d)
e)
(subependymal)
loss of
Neuroradiology 42
_______________________________________________________________________________________________
displacement of
displacement of cerebellar
osteolytic
osteoblastic
mixed
fibrous dysplasia
Pagets disease
*Secondary lesions
endocranial lesions
exocranial lesions
secondary lesions
a)congenital lesions
..
acoustic neuroma
trigeminal neuroma
9th, 10 th & 11th neuroma
c)chordomas
d)meningiomas
e)sellar lesions
tuberculosis
tumors
g)lesions of PNS
mucocele
squamous cell carcinoma
Neuroradiology 43
_______________________________________________________________________________________________
h)lesions of nasopharynx
rhinorrhoea + pneumocephalus
otorrhoea + pneumocephalus
PNS fracture
petrous fracture
CT brain
( lesions are congenital-traumatic-inflammatory-vascular-neoplastic-other; atrophy)
1- Congenital:
HYDROCEPHALUS: classification :-
1.non obstructive
2.obstructive
(non communicating)
1.congenital
senile dementia
familial cerebral atrophy
4.inflammation
following encephalitis
5.traumatic
6.neoplastic
b)obstructive hydrocephalus
Non communicating
congenital
acquired
-tumors
acquired stricture
-tuberous sclerosis
2.causes of 4th ventricular obstruction
-adhesive arachnoiditis
Neuroradiology 44
_______________________________________________________________________________________________
ambient cistern
communicating type
aqueduct
-tonsillar herniation through foramen magnum + normal 4th ventricle present in adults
(herniation till 3mm is normal but 10-15 mm = malformation)
-70%
syringomyelia & 5%
Type 2
boney dysplasia
(non comm.)
(comm.)
Type 3
-major deformities with cerebellar hyoplasia
Type 4: accompanied with high cervical or occipital encephalocoele
Communicating
-due to over production of C.S.F & absorption (this is a rare cause due to the presence of a
choroid plexsus papilloma)
-the cause is usually at tentorial hiatus
1.arachnoidal
occlusion of the
basal cisterns
2.subarachnoid space
subarachnoid hge
CSF absorption
non communicating
acquiductal
communicating
ambient
Neuroradiology 45
_______________________________________________________________________________________________
1)infants
finger prints
resoprtion of dorsum sellae
calcification
calcified ependyroma
pinealoma
tuberous sclerosis
* CT
-CT detects
effects of obstruction
site of obstruction
leak = haze
parenchyma
cause of obstruction
atrophy or not
sulci or not
ventricular dilatation
brain tissue
enlarged subarachnoid system & sulci
no periventricular haze (only type with no haze)
when unilateral
in aquiduct
or 4th ventricle
obstructive communicating
Neuroradiology 46
_______________________________________________________________________________________________
periventricular haze
absence of enlarged sulci (to differentiate between brain
.
in uteruo
1)it can detect congenital hydrocephalus in uterus in 17 weeks
2)it can diagnose midline shift in unilateral hydrocephalus
3)it can diagnose Dandy Walker syndrome
4)follow up of shunting operation
5)can diagnose intracranial haemorrahge
*Angiography
in absence of CT
-ventricular dilatation can be diagnosed by stretching anterior cerebral artery in lateral view
-downward displacement of internal cerebral vein
* MRI
* Isotope scanning
Agnesis of corpus callosum :-usually partial but sometimes complete
-CT appearance wide separation of medial borders of lateral ventricles between which the 3rd ventricle may
extend upwards + enlarged occipital horns (complete type)
-In partial agenesis it usually involves posterior part & anterior part may remain normal, frontal horns + bodies are
laterally displaced & small
-enlarged rounded occipital horns due to associated white matter hypoplasia
-lipoma may sometimes be found at site of the absent corpus callosum
-pathology
subdural hygroma
post-inflammatory locules
-clinical picture
if large
mass effect
hydrocephalus
-differential diagnosis
suprasellar
quadrigeminal cistern
NB:-tumors of posterior fossa & CPA
Neuroradiology 47
_______________________________________________________________________________________________
epidermoid
cerebellar
secondaries
primary(haemangioblastoma-medulloblastoma-astrocytoma)
rd
-tumors of 3 ventricle
colloid
ependymoma
teratoma
-tumors of sella
pinealoma
meningioma
adenoma
glioma
craniopharyngioma
absence of sulci
wh.matter e.g.of cerebellum or subcortically (i.e.abnormal glial tissue) occur in tuberous sclerosis
*Porencephaly
congenital
cavity lined by
* Holoprosencephaly: The cerebral ventricles are represented by a single cavity often expanded
posterior as a thin walled sac. The falx cerebri is absent.
Neuroradiology 50
_______________________________________________________________________________________
2. Subdural effusion.
3. Arterial and venous thrombosis infarcted areas related arterial or venous distribution
4. Focal zones of encephalomalacia and atrophy.
Encephalitis: Types:
1-Acute disseminated encephalomyelitis (ADEM): white matter ring or punctate enhancement in MRI+Gd
2-Acute haemorrhagic leukoencephalopathy: late evidence of petechial haemorrhage in MRI
3-Subacute sclerosing panencephalitis: post measles ccc by cerebral atrophy + white matter involvement.
4-Progressive multifocal leukoencephalopathy (PMLE): rare to enhance in MRI+Gd, hypodensities in CT.
5-Herpes simplex: multicystic encephalomalecia in infants / hypodensities in temporal lobe in adults.
Neuroradiology 51
_______________________________________________________________________________________
4. Ventriculitis or Ependymitis:
Ccc CT enhancement of ependymal layers along ventricular wall.
6. Sarcoidosis: (rare)
It can occur in C.N.S as: diffuse granulomatous meningitis Or
Neuroradiology 52
_______________________________________________________________________________________
Demyelinating disorders
2101
Congenital leukodystrophies: in childrens, low density white matter in CT, white T2W
symmetrical lesion usually spearing capsular region, well seen by FLAIR tech.
2- Canavan's disease, Alexander's disease: begins in frontal and extends towards occipital lobes.
2-
Disseminated sclerosis
2102
Unknown etiology; mostly slow virus. Multiple sclerosis is destruction of normally formed myelin.
Sites: in acute cases mostly periventricular, while in chronic cases mostly in optic pathway, brain
stem, cerebellum, spinal cord.
Radiological findings:
1-CT: low density plaques of white matter w can or not enhance if acute.
2-MRI: x 10 more sensitive: multiple hyperintense plaques, periventricular & in peripheries lies
within the convolutions, lesion are well seen in T2, FLAIR, DW images and they enhance
for long periods with Gd-EDTA (Dawson's fingers: perpendicular ovoid lesions to the
ventricles).
Senile
Uremia
LCF
HT crises
Malignancy
Muscle dystrophy
Vasogenic edema surrounding a brain tumor.
SPINE
Topics of comment on plain film of the spine:
1. General alignment
2. Vertebral bodies
7. I.V. foramina.
3. I.V.D
8. Ribs
9. Spinous process
5. Transverse process
Neuroradiology 53
_______________________________________________________________________________________
2.
3.
Neuroradiology 54
_______________________________________________________________________________________
Radiologically:
1-A small defect in neural arch.
2-Absence or deformity of spinous process.
3-There may be a little local widening of I.P.D at the affected level.
4-Associated spinal tumor may be at a higher level than S.B at lumbo-sacral junction on plain film.
N.B. In a patient with a neurological deficit: One should keep in mind that there is an association between Spina Bifida
Occulta with cutaneous abnormality. Also an association between congenital spinal tumors and a lipoma or dermoid
cyst of the filum terminalis or conus medullaris.
2. Meningocele or meningomyelocele
It is spina bifida with herniation of :
dural sac + leptomeninges meningocele.
dural sac + leptomeninges + elements of the spinal cord meningomyelocele.
Types of meningiocele:
1- Lateral thoracic meningiocele:
It is herniation of meningeal sac through wide I.V.F at margin of dorsal vertebra mostly due to
neurofibromatosis posterior mediastinal mass.
Plain: Well-defined, rounded para-vertebra soft tissue mass in the posterior mediastinium.
Myelography: Outlines the sac.
CT: confirms the diagnosis.
2. Anterior Sacral Meningocele:
It is herniation through a large bone defect in the anterior sacrum into pelvis.
Plain: Soft tissue mass in the pelvis.
Barium Enema: Displacement of recto-sigmoid.
Myelography & CT: Confirm diagnosis.
3-Meningo-myelocele:
A.P.: spina bifida + bony defect of neural arch, widening of the spinal canal (wide I.P.D)
Lateral: Soft tissue mass is outlined
Dysraphism : d.t.:
1. Adhesions bet ectoderm & endoderm of embryonic disc prior to formation of the notochord at the 3rd week of gestation.
2. Derangement of normal sequential closure of the neural tube & its separation from the dermis, followed by in-growth of
mesoderm to form meninges. Eg: Myelomeningocele - Lipoma - Epidermoid & dermoid tumors -Dermal sinus-Diastematomyelia
Diastematomyelia:2169
pedicles +/-
Neuroradiology 55
_______________________________________________________________________________________
Spinal infections
Spinal infections include cord affections & bone affection (mainly in dorsal spines).
Inflammatory disease of spine (now called discitis osteomylitis) include involvement of disc
together e opposing parts of vertebral end plates, it include --> non specific discitis & Pott's disease
(T.B of spinal but staph can affect spine). N.B. no spinal bony affection without disc affection.
1. Non specific discitis
- Low grade inflammation e no aggressive spinal affection & non-significant abscess formation.
- Narrow (inflamed) disc space + eroded vertebral end plates.
- Occurs mostly as a post-operative complication, mostly in lumbar region (look for laminectomy)
2. Pott's disease of the spine
a- PXR: aggressive infl. process resulting in narrow disc space + eroded vertebral end plates.
- Multiple level affections usually occurs, mostly in dorsal region.
- Significant abscess formation occurs in back muscle region, paravertebral region (on both sides),
prevertebral region (iliopsoas to groin) +/- inflammatory granulation tissue in epidural region
(intraspinal) that enhance after IV contrast. Abcess formation is best seen non axial images &
eroded end plates on lateral x-ray and sagittal MRI.
b-CT images:
- Once vertebra above & below disc level are affected in an inflammatory process, disc will be
affected even if no significant radiological changes are seen in it:
- Affection of disc is very mild occurring in form of: non significant bulge - haziness
- Affection of vertebral and plates above & below disc level: eroded end plates e rarifactions
(sclerosis may also occur in low grades of inflammation as there is chance for healing).
So on CT search for level of disc then go one level above and one level below the disc lesion.
D.D:
1-Multiple Schmorl's nodes: occurring in vertebral end plates (above & below disc) but they are of well
defined margins + sclerotic margins.
2- Metastatic deposits: ccc by normal disc in between, mostly affects pedicles & body (not end plates) +
history of 1ry malignancy (no history of spinal operation).
N.B: most intraspinal lesions are neoplastic but other may occur w are haematomas or inflammations.
- T2W: white disc + white end plate is not truly homogenous (as patient while under ttt there will
be part responding and ports not responding).
- Axial cuts + coronal cuts: detect paravertebral abscess. If this abscess press on cord = myelitis if
white in T1W+Gd, and = edema if white on T2W.
Neuroradiology 56
_______________________________________________________________________________________
- So in ?? spinal infection on MRI --> see sagittal T2W --> diffusely white disc (due to
inflammation) & ensure that they are black on T1 images + white on T1W+Gd.
Neuroradiology 57
_______________________________________________________________________________________
Spondylolithesis :
1845
Definition:
Forward slipping of one vertebra above on a vertebra below due to a fracture in pars interarticularis,
i.e. forward sublaxation of vertebral body, pedicles, & sup. articular processes, while lamina,
spinous process and the inferior articular process main in normal position.
Reversed spondylolithesis: may occur in following: rheumatoid arthritis, ankylosing spondylitis,
trauma, OA of apophyseal joint.
Spondylolithesis: usually leads to adjacent disc degeneration or prolapse (sublaxation annular
tear spondylitic changes).
Spondylolysis: pars interarticularis defect without vertebral slipping.
N.B: In all types of spondylolithesis the I.V.D at the level of the slip projects posterior to the plane of the
displaced body. This should not be misinterpreted as a significant disc prolapse or protrusion unless there is
considerable encroachment of the epidural fat between the disc and theca rost sheath.
2.
Fibrosis rather than bony union between the separate ossific centers.
3.
4.
Predisposing factors:
1. Congenital hypoplasia of articular processes.
2. Trauma: stress fracture of pars interarticularis, acute fracture of pars interarticularis
3. Degenerative O.A changes in apophyseal joint.
4. Pathological fracture i.e. T.B, Pagets disease.
Radiologically:
A.P.:
Bow line extensive form. Owing to the associated lordosis of L5 vertebra, it is viewed in AP view
to be super imposed on sacrum bow line.
Lateral:
Neuroradiology 58
_______________________________________________________________________________________
- Will show if defect of pars interarticularis is present and whether it is bilateral or unilateral.
- Defect appears as a gap in neck of Scottie dog.
- Margin of defect are well defined & width of then gap varies with degree of forward displacement.
- When displacement is progressive 2ry deformities of body of 5th lumbar and 1st sacral segment.
- Eye: pedicle
- Ear: superior articular process.
- Nose: transverse process.
CT:
Look for the pars at the level of the pedicle at disc level you will see apophyseal joint.
1. fracture of pars interart. (sclerosed, irregular margins).
2. disc state.
Myelography: For any evidence of indentation or disc protrusion.
MRI of spondylolisthesis:
1. Degree of slip & neural compromise.
2. Lack of signals from sclerotic but intact bone which may simulate a break.
2. Degenerative:
1.
signs.
Prolapse into an adjacent vertebral body corticated erosion of vertebral body [Schmorls
2.
node].
3.
Prolapse through post. or postero-lateral margin of annulus pain with neurological signs due
to:
pressure on spinal cord. Or pressure on nerve roots in I.V. foramen.
4. Calcified disc prolapse especially in dorsal region may simulate a meningioma.
Site:
Neuroradiology 59
_______________________________________________________________________________________
The commonest site for disc prolapse is L4-L5 then L5-S1 then L3-L4 (maximum anglulation,
weight bearing.)
Lower cervical: C5-C6 & C6-C7 ( most mobile).
Stages: read
a)Disc bulge:
- outside disc space,
- inside disc space pressure: schmolers node sclerosing margins (i.e. protrusion without
focality).
Posterior
Posterior lateral
Infra lateral
Rupture annulus.
c)Migration: Herniated nucleus ascends or descends from original disc space
migrated disc has the same CT density & MRI signal on both T1 & T2.
d) Sequestration: Same as migration but with loss of connection of migrated protruded nucleus
from original nucleus.
Fragment has high signal on T2 W.
Radiology Appearance:
A. Plain findings:
1. Completely normal in acute disc prolapse.
2. Narrowing of I.V.D space (symmetrical or on one side).
3. Alteration of the spinal alignment (flattening or scoliosis) due to reflex spasm of paravertebral muscles to tension on the nerve roots being stretched over protruded disc.
4. Blunting of edges
5. Sclerosis of edges of adjacent body
6. Vacuum sign (degenerated disc material traps nitrogen gas from blood).
7. Calcification in disc.
8. Spondyolitic changes in body or facet joint: osteophytes.
9. Cause (trauma, fused vertebra....).
B. Myelographic findings:
I. General: cardinal signs :The cardinal signs are considered diagnostic provided it is constant.
I. In. lateral film:
Indentation (Extradural) of anterior margin of omnipaque column, seen with posterior disc
herniation rather than lateral disc herniation the level of affected disc.
Neuroradiology 60
_______________________________________________________________________________________
2. AP view:
A) Post. disc: hour-glass constriction of the ominipaque column, (central disc + lig. flavum hypertrophy.)
horizontal, serrated defect of the ominipaque column
B) Lateral disc lateral indentation in ominpaque column.
C) Obliteration or deformity of affected nerve root sheath (amputation of root sleeves) d.t. edema.
D) Block defect either partial or complete to subarachnoid spaces if large disc protrusion:
asymmetrical filling lat film Rt. & Lt.
CT findings:
Disc herniation diffuse or localized, encroachment on the epidural fat with entrapment of nerve
root at the exit foramina.
MRI:
- Annulus fibrosis, spinal ligaments dura matter and cortical bore low signal
- Vertebral bodies, nucleus pulposus high signal (white).
1- It is only non-invasive technique that shows nucleus of the disc.
- Epidural and paraspinal fat good delineation of dura high signal of the fat around low
signals of dura.
2- C.S.F has long T1 & T2 low signals (block) using short echo delay time.
- A shelf of annulus causes a low signal horizontal band gives a characteristic bilocular appearance
of the nucleus.
- With normal aging intensity of signal of nucleus.
3- Nucleus pulposus of normal IVD, high signal or T2 weighted, which is surrounded by the low
signal of the annulus which also partly divides the nucleus giving the characteristic biocular
appearance of the adult nucleus pulposus.
4-. The signal returned from the degenerated nucleus is low due to dehydration associated with degeneration
with indentation of the thecal sac by the protruded disc.
5-On T2 weighted MRIs the disc returns to a higher signal than the scar, in which signal decreases with
aging. Recent scars enhance immediately but old scars enhance more slowly and much less. Gd enhanced
MRI is more accurate than CT in this assessment.
Focal Varicosities:
Caused by disc compression on vertebral venous plexus focal dilated veins. It may also occur in
angiomas & spinal canal stenosis. Normal myelogram + narrow disc = anterior protrusion.
Spondylosis
Definition:
- It is a bony overgrowth in adjoining vertebral margins due to long standing herniation or
degeneration of an intervertebral disc. It is a descriptive term referrning to defects in the region or
Neuroradiology 61
_______________________________________________________________________________________
the pars interarticularis or a vertebra. It most commonly occurs at the 5th lumbar vertebra.
- Elevation of periosteum from edge of vertebral body allowing osteoblasts to lay down new bone
so a bulge is formed compress nerve root i.e. starts as lipping due to friction caused by
flattening of bodies then redundancy in ligaments bone laying.
N.B. Spondylosis degeneration
Spondylysis pars defect without slippage.
Spondyelythesis pars deject with slippage.
Radiological appearance:
1. Schmorls node: Traumatic or developmental defect in the cartilaginous end plate vertical
herniation of nucleus pulposus indentation of adjoining margin of vertebral body with s
sclerosing margin which is seen in the lateral film.
2.
Osteophytic rim: May be seen on the posterior margin of vertebral bodies extending to
I.V.F compression of nerve roots at their exit from spinal canal.
3. Subchondral sclerosis and irregularity of the surface of vertebral body adjoining the disc space.
4. Lateral films with flexor & extensor sublaxation & abnormal mobility.
5. Calcification in nucleus or annulus. More in thoracic vertebra and differentiated from thoracic
meningioma.
6. Narrow disc space with marginal sclerosis and osteophytosis.
7. Post indentation of omnipaque column by thickened ligament flavum.
8. Vaccum phenomena: radioluncent collections of gas crested by abnormally altered disc spaces.
4.
5.
Annulus protusion.
6.
Neuroradiology 62
_______________________________________________________________________________________
AP diameter canal
4.
Pedicles:
5. Apophyseal joints: Vertically oriented, distinct joint space, present inside pedicles.
6. Inferior articular process: convergent., encroaching on AP diameter of the canal (lat view)
B) Myelographic findings:
1. Suggestive data:
a. Difficult lumbar puncture with the best hand.
b. Pain with injection of dye.
c. Whole dural sac of lumbar vertebra is filled with less than 6ml of dye in the standing position.
2. Definite data:
a. Beading of dural sac opposite disc spaces.
b. Post. scalloping of the opacified column.
c. Crow dening of the nerve roots.
d. Worm like appearance of the venous channels.
C) C.T findings:
1. Absent epidural fat & short bulky pedicle .
2. Medially placed epipth at the pedicular.
3. Bony surface area < 1.42 cm.
4. Soft tissue surface area < 100 mm.
5. Mid Sagittal diameter is less than 10mm in cervical 12 mm in lumber.
Neuroradiology 63
_______________________________________________________________________________________
B. Wedge fracture:stable.
1. in anterior vertebral height of involved body.
2. Disruption of anterior cortex of involved body.
3. + haematoma para vertebral soft tissue shadow.
C. Clay shavellers fracture:
Stress fracture of a lower cervical spinous process in coronal plane.
Neuroradiology 64
_______________________________________________________________________________________
F. Pillar Fracture:
It is vertical fracture of articulmass (pi) resulting from impaction of involved mass by
ipsilateral superior articular mass during hyperextension & rotation.
Neuroradiology 65
_______________________________________________________________________________________
Atlanto-Axial Subluxation:
- The maximum normal distance between the cortical margins of the arch of atlas and the odentoid
is 2.5 mm in adults and 5mm in children. In atlanto-axial subluxation and dislocation may cause
acute or slowly progressive quadiparesis.
It may be secondary to:
A)
B)
C)
A.O. ass
Spinal Tumors
A. Extra dural:
1. Benign:
1. Meningioma
2. Neurofibroma
3. Dermoid
4. Lipoma
5. Extradural cyst, abscess, haematoma.
6. Vertebra: Hemangioma
Osteoblastoma
Aneurysmal bone cyst.
2.
Malignant:
1. Primary vertebral tumors: Solitary myeloma
Chordoma
Chondro-sarcoma
2. Secondaries:
Neuroradiology 66
_______________________________________________________________________________________
3.
- breast, lung due to wide venous and lymphatic connections of extradural space.
- lymphoma.
Non neoplastic:
1. Prolapsed disc
2. Spondylosis,
3. Extradural archnoid cyst
4. Pagets disease: by vertical compression of softened vertebra
5. Osteomyelitis
6. Trauma
7. Extra medullary haemopoiesis.
B. Intra dural:
I. Extra-medullary:
1.
Benign:
1.Meningioma,
2. Neurofibroma,
3. Lipoma,
DD with extradural causes
2.
1.
Malignant:
Seedlings of metastatic deposits from glioma or carcinoma via the CSF.
II. Intramedullary:
1.Neoplastic:
1.
Gliomas: astrocytoma,
ependymoma.
2. Haemangioblastoma.
3. Teratoma,
2.
3.
4.
5.
2. Non neoplastic:
1. Syringomyelia
Arnold-Chiari Malformation.
Haematoma
Post radiation myelopathy
AV malformations
Thick dura: Syphilitic pachymeningitis, metastases, mps deposition
Multiplicity: neurofibromatosis, metastases from CNS. metastases from other tumors, meningioma
(rarely).
Radiological Approach:
I. Plain: only in 20% of patients.
A. A-P.
1. Bone destruction and erosion.
2. Destruction of pedicle.
3. Expansion of the vertebral canal (wide I.P.D., thin flat pedicle).
4. Para-vertebral soft tissue mass.
Neuroradiology 67
_______________________________________________________________________________________
Special features:
I. Extra-dural
A. Benign
Plain
Myelography
Neuroradiology 68
_______________________________________________________________________________________
a. Flattening of pedicle.
b. Thinning
c. Wide I.P.D
d. Scalloping of post. vertebral margin
in lat view
B. Malignant
II. Intradural T. A.
extra-medullary
B. Intra-medullary:
(ependymoma
is
commonest).
in children
Criteria of malignancy :
1. In metastatic disease normal I.V.D
d.d from T.B
2. Erosion of pedicles (or destruction)
3. Abnormal sclerosis of vertebral body
4. Destruction of Vertebral bodies &
appendages
5. Pathology. fracture.
6. Soft t. mass with myeloma
chordoma calcification
7. Cord compression by 1ry vent. tumors
Meningioma :
1. Normal
2. Bone erosion (rare)
3. Flat one pedicle
4. Calcification D.D with calcified
I.V.D.P narrow I.V.D calcifc.
opposite disc osteophytic lipping of
vert. margin.
5. Angioneurofibroma hourglass,
dumb-bell tumor.
a. Bone erosion
b. Expansion of I.V.F (oblique view).
c. Wide vert. (I.P.D)
d. para-vert. Mass
e. Erosion of vert. endo of ribs.
f. Post. scalloping g-scoliosis
Uncommon
1. Fusiform enlargement of the spinal
cord and sometimes of the vert. canal.
2. Ependymoma great expansion and
erosion of lumbo-sacral canal (giant
tu. of cauda equina).
3. Glioma minimal erosion expansion
of the vert. canal due to shorter
history & neurological disability is of
rapid onset.
- It occurs anywhere in the cord.
N.B.Meningioma:
Angio nidus which is central with radiating vessels (star) vascular blush.
N.B. Calcification is like small gr& usually dat the periphery.
Neuroradiology 69
_______________________________________________________________________________________
3. Mass as regards to: site of origin, (extra-dural, extra-medullary, intra medullary), nature (density)
4. Density by CT:
a. High attenuation: Meningioma, haematoma, calcifications.
b. Low attenuation: Lipoma, cystic disease, congenital tumors.
c. C-S.F attenuation: Syringomyelia, hydromylia.
Neurofibroma
-
2- Solitary neurofibroma .
3- Acoustic neuroma ( 8th CN ) deafness & ICT
Plain X-ray findings:
i. Bone erosion (DD with meningioma.)
ii. Scalloping of posterior border of vertebral body.
iii. Expansion of inter-vertebral foramina.
iv. May expand into para-spinal mass called hourglass or dumb bell tumor. It may then
cause splaying apart or erosion of vertebral ends of ribs.
v. Expansion of spinal canal (widening of inter pedicular space & thinning of pedicles).
vi. Myelogram: same as meningioma except for lack of sex or site preference &
calcification.
vii. Occurrence in cauda equina giant tumor of cauda equina.
CT:
- Neurofibroma is larger than meningioma, occurs at any level with erosions.
- No calcifications (meningioma: califications at the periphery).
- IV contrast: enhances of the tumor more than in meningioma.
- Both tumors: Flat cord and displaced, widening of the subarachnoid space.
MRI:
- 2/3 are intradural and the rest are either entirely extradural or having an extradural componant.
Low on T1 and high on T2 and enhances on Gd injection.
- Upper & lower borders are outlined against extradural fat behind spinal cord after gadalium
tumor enhance & its outer border is compressing dura is evident.
Associations : *MEN IIb
Neuroradiology 70
_______________________________________________________________________________________
* Carcinoid tumor
* Gardners syndrome ( Familial polypi + Osteoma )
* Tarcots syndrome
Complications: 1- infection
2- cystic change
3- malignancy
SYRINGOMYELIA imp
Partial mechanical obstruction to C.S.F outflow from 4th ventricle thus C.S.F is funneled into upper
part of central canal of spinal cord (instead of passing into cisterna magna) leading to cystic
cavitation of the cord. Hydrocephalus is unusual.
Causes of foramina obstruction:
1. Chiari malformation (90%) with downward prolapse of cerebella = tonsils through foramen M.
2. Basal adhesive arachnoiditis (1/3 of cases).
3. Dandy-Walker syndrome.
Syringomyelia behaves like intra medullary tumors (cystic degeneration & gliosis in the central
canal leading to cord expansion).
Radiological appearance:
1. Plain film is normal is most cases.
2. Thinning of pedicle and widening of inter pedicular distance.
3. +ve contrast myelogram:
a. Prone expanded cord with free flow of myodil (usually cervical).
b. Supine outlining of herniated cerebellar tonsils.
4. Air myelogram: phenomenon of the collapsing cord
Head down: Cx cord appears swollen (cavity full with fluid).
Head up: Cx. cord appears thin (cavity empty).
ANGIOMA
A.V malformations usually on dorsal aspect of the cord
Pt usually presents with progressive cord malacia.
Radiological appearance:
1. Plain film: normal.
2. Myelogram: tortuous serpiginous linear defects in the opaque column extending over several
segments (mainly due to dilated feeding arteries & draining varies).
Hydromyelia:
It is a simple dilation of the central canal of the spinal cord. It may communicate with the fourth
ventricle with or without imperforate foramen of Magendi. It is a congenital lesion usually
associated with:
Chiari II malformation manifest dysraphism (if hydrocephalus has responded to treatment).
Neuroradiology 71
_______________________________________________________________________________________
Or
- Hydromyelia extends from and usually is confined to lower segment of spinal cord. It may be
associated with occult spinal dysraphrism especially diastematomyelia.
- The cord does not expanded as the surrounding gray & white matter are atrophic. The size of the
cord may change with posture, with the patients head down the cord is normal or enlarged, or
the patients head up ribbon like.
Radiological Appearance:
Plain film:
It is impossible to distinguish between syringo or hydromyelia and an intra-medullary tumor on
plain film unless there are associated developmental abnormalities such as:
basilar impression
occipitalization of atlas
fused cervical vertebrae
- Widening of spinal canal usually due to Arnold-Chiari malformation.
CT: delayed C.T scan revealed pooling of C.M. into spinal cord by diffusion effect.
ARACHNOIDITIS:
Infiltration of the meninges with chronic inflammatory cells and fibrosis.
Causes:
1.
2.
The sacral cul de-sac is shortened and the outline of the theca is smooth.
3.
Nerve roots in cauda equina is adherent to each other single irregular longitudinal
structure.
4.
Neuroradiology 72
_______________________________________________________________________________________
Chronic anemia.
4. CT tumors:
Lipoma, fibroma.
Marginal calcifications.
Fluid levels
I. Neoplastic diseases:
A. Metastasis: breast, bronchus, prostate, kidney .
Incidence: accounts for majority of patients with a solitary spinal metastasis.
Type: Lytic, scleroor mixed
I.V.D are preserved. Associated pedicle destruction.
B. Plasmacytoma :
The vertebra is a common site of plasmacytoma.
- May mimic an osteolytic metastatic lesion expansile & resemble an neurysmal sipt.
- Intact I.V.D spaces.
- Associated para verterbral soft tissue shadow.
C. Lymphoma:
Types: as metastasis.
Neuroradiology 73
_______________________________________________________________________________________
-Intact I.V.D.S.
Associated features: involvement of other bones i.e. pelvis.
D. Benign tumors:
1. Haemongioma.
2. Aneurysmal bone cyst.
II. Trauma:
1. Discontinuity of trabeculae.
2. Sclerosis of the fracture line.
3. Disc space usually preserved.
4. Usually no soft tissue mass.
III. Osteoporosis:
- Reduced bone density
- Vert. body may be wedged or biconcave (fish shapes)
IV. Infection:
Destruction of end plates adjacent to destroyed disc.
Pyogenic
T.B.
1. Rapidly progressive.
1. Slower
2. Marked sclerosis
2. Less sclerosis
3. Marked collapse
5. Not early
IV. Histocytosis:
1. Eosinophilic granuloma is most common causes of solitary vertebral plana in a childhood.
2. Affected vert. body tends to bulge laterally.
3. Para-vert-soft tissue shadow.
4. Disc spaces remain intact & may be widened.
VI. Sickle - cell anemia:
- Generalised depression of central portion of the vertebral plate.
- Sometimes, depression is flat & sides slope obliquely
VII. Scheuermanns disease:
1. Irregular end plate.
2. Numerous schmorls nodes in thoracic spine.
3. Disc spaces narrowed.
4. Degenerative changes.
5. Progressive to sever kyphosis
Neuroradiology 74
_______________________________________________________________________________________
2. Pagets diseases.
3. Psoriatic arthropathy
4. Rheumatoid arthritis.
Block vertebrae:
1. Isolated congenital:
- Failure of segmentation, the ring epiphyses of adjacent vertebra dont develop
resulting a large AP diameter.
- Most common in the lumbar region.
- The articular facets, neural arches, spinous processes may be involved.
2. Klippel - Feil syndrome (cervical)
2. Rheumatoid Arthritis spinous processes dont fuse.
3. Ankylosing spondylitis
4. TB
6. Post traumatic or operative union.
Neuroradiology 75
_______________________________________________________________________________________
Narrowed I.V.D.S.
scoliosis in 50-70%.
2. Neurofibromatosis.
3. Intra-spinal mass : esp. ependymona.
4. Diastematomyelia.
2. Tumor
Neuroradiology 76
_______________________________________________________________________________________
Trauma
2.
SCOLIOSIS:
A. Idiopathic:
1. Infantile: before 4 years of age, 90% are thoracic and concave to the right.
90% resolve spontaneously.
2. Juvenile: 4 to 10 years of age, more common in females, progressive.
3. Adolescent: more common in females, majority are concave to left in thoracic region.
B. Congenital:
1. Failure of formation:
a.
b.
c.
Multiple hemivertebra.
On the same side severe
Hemivertebra on opposite sides may composite each other.
d.
Neuroradiology 77
_______________________________________________________________________________________
Neuroradiology 78
_______________________________________________________________________________________
Infective:
a.
chronic osteomyelitis
b.
f. Sarcoidosis.
Neuroradiology 79
_______________________________________________________________________________________
3. Fibrous dysplasia.
4. Myelosclerosis: spleenomegaly.
5. Renal osteodystrophy.
6. Fluorisis: mottling of the tooth enamel, axial skeleton is most frequent site.
7. Acromegaly.
8. Chronic haemolytic anaemia.
9. Congenital: a) osteopetrosis; bone-in-bone appearance.
b) pyknodysostosis: wormian bones especially in base + wide sutures.
5. Neurofibromatosis.
6. Achondroplasia.
3. Megalencephaly
7. Hydranencephaly
4. Storage diseases.
Wide sutures:
Birth to 1 month suture width > 1cm, after > 3 month suture width > 3mm
1.
2.
Arachnoid cyst:
Neuroradiology 80
_______________________________________________________________________________________
Arachnoid
Perineural
Extradural
Intradural
Duplications of arachnoid or
abberent
of
traumatic
thoracic congenital
related
septations
neural
canal
(DD
neuro fibromatosis)
N.B.: Arachnoiditis: arachnoid matter is devoid of blood vessels so, no inflammation can occur. However, inflammatory process
involves subarachnoid space & pia matter to with arachnoid becomes adherent via organization of the exudate.
On myelography :
1. Complete black with irreg. configuration
2. Smooth featureless thecal sac in which the roots or root sleeves are visible
3. Irreg. opacification of subarachoid space
4. Thickened roots or nor filling of sleeves.
Neuroradiology 83
________________________________________________________________________________________________
ORBIT
- A.P. diameter (globe) = 22 mm, optic nerve thickness = 4mm
- Conal = structure inside muscle gp of eye, extraconal lesion will be outside as lymphoma
- Lamina paparecia is lateral wall of ethmoid sinus & medial wall of orbit along which inflammation
of ethmoid sinus extends to orbit
How to think on a film ?
- Child: retinoblastoma, rhabdomyosarcoma, metastases from neuroblastoma, optic n. glioma
- Adult: haemangioma, orbital meningioma
- Old age: lymphoma, pseudotumor, metastases
~ Special features: pulsation (AV malformations aneurysms)
increase on straining (orbital varices), thyrotoxic
Investigations:
1-PXR
2-CT: location of lesion if orbital, paraorbital and demonstration of calcifications+enhancement
3-Ultrasound + doppler
4-MRI
5-Orbital venography + carotid angiography
Neuroradiology 84
________________________________________________________________________________________________
2. Tumors of orbit:
1- 1ry orbital meningioma - Orbito-sphenoidal meningioma(see before):
~ Meningioma of optic nerve sheaths:
- From meningioblatic rests in dura matter covering optic nerve, it cause proptosis before
compression on optic n. (it doesn't infiltrate it) + decrease VA + constriction of field of vision.
Neuroradiology 85
________________________________________________________________________________________________
a) PXR:
1- Localized / generalized orbital enlargement
2- Hyperostosis of orbital walls
3- Changes in adjacent sinuses: pneumosinus dilatans2250: it is a sign of presence of occult
meningioma when detected on plain film you must go to CT or MRI occurs in form of abnormal
dilatation of one of PNS containing only air & lined by normal epithelium.
Commonly seen in sphenoid sinus in cases of meningioma of tuberculum sellae or planum sphenoidale
b) CT:
1- Before C: diffuse enlargement of optic nerve + thickenned
2- Marked contrast enhancement (> optic glioma) after C injection
3- Optic canal narrowed if hyperostosis is present or optic canal enlargement in cases of invasion.
4- Calcifications (psammomas) mau be visible along course of optic nerve.
5- Must look at intracranial portion of optic nerve to exclude extention.
c) MRI: low on T1 & T2 with strong enhancement after Gd-EDTA, excellent to show
extension through optic canal, fat suppression technique could be used for better
evaluation.
1- Optic Nerve Glioma
2- Meningioma
2- Retinoblastoma
-AD, most common intra-occular malignancy in childhood arise from retinoblast & in 1/3 of
cases is bilateral
-Age: 18 m
a) Ultrasound:high echogenic mass e shadowing in posterior globe + doppler: increased flow
b) CT: diagnostic procedure & only 10% of retinoblastomas lack calcifications, it is seen
as a partially calcified intra-occular (intra-conal) mass involving retina which shows marked
contrast enhancement & thickening of optic nerve may indicate extension of tumor to the
perineural subarachnoid space
c) MRI: high T1 & low T2 (opposite to normal) & it is the best in evaluation of transscleral or
perineural spread
- In absence of dissemination; enucleating & radiotherapy may be curative but extension into
predicts a very poor prognosis & recurrence rate is high, must look in all familly members.
3-Malignant melanoma 2233
- >50 yrs, usually unilateral
a) U/S: mass causing scleral thinning + >1mm elevation + doppler
b) CT + MRI: post globe affection, high T1w, low T2w signals.
c) Bone scan could be done to evaluate metastasis to long bones + liver + lung.
Neuroradiology 86
________________________________________________________________________________________________
4-Rhabdomyosarcoma
-Rare, muscular malignant orbital tumor in children
-Cl/p: rapidly progressive exophthalmos + superficial swellings of eyelids & canthi
a) PXR: progressive enlargement of orbit +/- bone destruction e extension to temporal fossa, PNS.
b) CT+MRI: bulky tumor mass with anterior location in orbit involving an extra-occular muscle
(isodense on CT ) & may extend intra & extraconally + strong enhancement
+ bone destruction + extension to infra-temporal fossa & cranial cavity.
5- Lymphoma
- Non-Hodjikin lymphoma, from anterior orbit outside muscle cone, > 50 yrs.
-CT: mass in anterior orbit extraconal in position enveloping globe, no bone erosion
ressembles rhabdomyosarcoma.
- DD: pseudo tumor metastasis Myeloma.
6- Metastasis
- From neuroblastoma (w is the commonest cause of proptosis in children + Histocytosis X),
Ewings, Wilms & leukaemia in children
- Osteolytic lesions are commonly seen, osteoblastic from cancer prostate, breast, lung & stomach
(in elderly)
- DD: pseudo tumor metastasis Myeloma - rhabdomyosarcoma.
a) PXR: ill defined lesions with osteolysis or sclerosis of orbital bones
b) CT: bone involvement, soft tissue mass, extra ocular muscles may be involved especially
medial rectus ms, marked contrast enhancement
7-Neurofibromatosis
- Enlarged orbit + optic canal (associated optic nerve glioma in NFI)
- Elevation of sphenoid ridge to level of orbital roof , MRI: intermediate signal in T1 & T2.
- May cause large defect in greater wing of sphenoid (lost boundary of orbit): encephalocele
leading to pulsating exophthalmos d.t. transmission of cranial pulsations to orbital contents
called: "bare orbit" of neurofibromatosis on P.A view
8-Dermoids & epidermoids
- Dermoid is cystic (may contain fat, cholesterol & hair)
- Epidermoid is solid mass of desquamated cells with a capsule, site for both:
1)diploe of skull expanding both inner & outer table, sharply demarcated bone defect of skull
with well defined sclerotic margin
2)in orbit arise from supero-lateral quadrant (commonest), or from medial part of orbital roof
-CT: dermoid gives localised area of low attenuation of fat (-50 to -150 HU) superficially
located periorbital dermoids give shallow localised indentation on orbital rim.
9- Lacrimal gland tumors
a) Benign: pleomorphic ademona: local enlargement of lacrimal fossa without bone erosion
b) Carcinoma: in 50% may cause only local enlargement of lacrimal fossa without bone invasion
-CT show signs of malignancy: bony invasion & sclerosis of adjacent bones of lacrimal fossa,
calcification (diagnostic) in the tumor, extension of mass outside the fossa (intracranially)
c) Lymphoma: elderly, CT shows mild enlargement of the gland + no bone erosion.
Neuroradiology 87
________________________________________________________________________________________________
1- Assoc. sinus infection + fluid level in sinus (to diff. preseptal cellulitis from orbital cellulitis)
2- Widening of extraconal space between ethmoid & orbite d.t. edema or abscess formation.
3- Local rectal muscle enlargement (extension of inflammatory process)
4- Soft tissue gas with or without fluid level
5- Ring enhancement after IV contrast suggest abscess formation.
b- Chronic infection ( Pseudo-tumors = Idiopathic orbital inflammation )2039:
- AD, unknown cause, most common cause of an orbital mass in adult
- Unilateral, resembling clinically orbital tumors & Grave's from w it is differentiated by
pathological examination and giving response to steroid therapy (very imp!).
-site: in order of frequency: lacrimal gland, extraoccular ms, sclera, optic nerve and fat
a) PXR: only clouding of nasal sinus d.t. infection or nasal polyp.
b)CT:
1- Loss of def with surrounding; infiltrative lesion e irregular ill defined edge of variable density
2- May show extraoccular ms enlargement; ant. portion (dd from Graves disease is by the fact
that IOI involves lacrimal gland, extraoccular ms tendinous insertions, sclera, optic nerve and
fat + usually on one side + normal thyroid fnc)
3- Markly enhancing enlarged optic nerve and sclera.
c)MRI:
- Like CT, low T1 & high T2 MRI signal intensities as Grave's (versus fat & muscle), thickened
sclera, enlarged optic nerve, sometimes simulating a mass.
Hyperostosis in orbit:
1. Meningioma.
2. Sclerosing metastasis eg neuroblastic reduced size of orbit.
3. Fibrous dysplasia: reduced size of orbit.
4. Pagets diseases.
5. Osteopetrosis.
6. Chronic osteomyelitis adjacent to ch. infected frontal sinus.
7. Tumor of lacrimal gland.
8. Radiotherapy.
Neuroradiology 88
________________________________________________________________________________________________
-CT
will show soft tissue as density attached to bone & replacing air in sinuses
b)loss of translucency
-vary from a minimal loss to complete opacification
-to estimate degree of opacification compare with that of opposite side or adjacent orbit
c)fluid level
-may be seen in any sinus (mostly in antrum) except ethmoid
d)deviation of nasal septum
-anterior deviations are clinically diagnosed
-posterior deviations will be demonstrated on O. M or CT
-associated soft tissue masses due to edema of nasal mucosa or nasal polyps
e)alteration of bony contours
-pressure from soft tissue mass
-interruption of a contour may be seen with a fracture
f)alteration of bony density
1.bone may be thin or destroyed by
2.absent bone
surgical
3.increased density
generalized disease
Pagets disease
fibrous dysplasia
localized disease
chronic infection
adjacent malignancy
3.normal variation
Inflammatory diseases of sinuses :-
Neuroradiology 89
________________________________________________________________________________________________
infected tooth
-primary site of infection is mucosal lining of sinus & accompanying swelling of mucosa will show
as an opaque rim (due to out pouring of fluid into sinus cavity) around periphery of sinus
-opaque sinus on plain x-ray (differential diagnosis blood or new growth) & fluid level
NB :@ acute sinusites = thick mucosa + fluid level + osteomeatal complex
@ chronic sinusites = thick mucosa + obliteration of sinus cavity + bone density
-radiological signs (plain CT MR-T2)
fluid level
-an acute sinusits causes air-fluid level in sinus with pain, fever & localized tenderness
-fluid may be seropurulent, blood or CSF
-differential diagnosis
mucosal thickening
-it is measured as distance between medial edge of lateral soft tissue shadow & lateral wall
of antrum & if > 7mm thickness it is usually associated with purulent fluid
rounded densities in antrums
-well defined with rounded or scalloped margins
osteo-meatal complexes, nasal septum & conchae
loss of bone density
-commonly in ethmoid & the cause is
1.mucosal thickening contrast between soft tissue & bone
2.resorption of bone from hyperaemia of mucosa
increased density of bone
-seen with chronic sclerosing sinuisits
-complications of sinusites
I. obstructive (mucocoeles)
-pathology
obstruction of ostium of sinus
distension of sinus
Neuroradiology 90
________________________________________________________________________________________________
-clinical picture
-plain x-ray
soft tissue mass within one half of frontal sinus, bulging across the midline with a convex
outer margin, out lined against air in other half of sinus
erosion of upper medial half of orbital margin
expansion of sinus cavity characteristically causing loss of scalloped margin of the
normal sinus wall
forward bulging of anterior wall of sinus
thinning of walls of frontal sinus
sinus is more opaque than normal due to fluid in its cavity
-CT
-MRI
optimum technique for demonstration of mucocoeles
low T1 & high T2 (the most usual)
total absence of enhancement confirms the fluid content
mucocoele of sphenoid sinus :
-clinical picture
-plain x-ray
lesion expands sphenoid sinus resulting in elevation or destruction of floor of sella on
lateral skull film
progressive expansion
-CT
Neuroradiology 91
________________________________________________________________________________________________
via venous
CT demonstrate
with loss of outline of sinus wall followed by frank osteolysis & sometimes bone sequestration
-site
rotation of patient
under exposure
b) Outside antrum
d) Inflammatory
e) Trauma
f) Neoplasm
g) Granulomatus
Neuroradiology 92
________________________________________________________________________________________________
Nasal polyps
-features
choanal polyp
antrochoanal polyp
-simple nasal polyps are pedunculated edematous respiratory tract mucosa & can arise from any
part of nasal mucosa & are often multiple & bilateral
-commonest site of origin is mucosa of ethmoid cells & less commonly they arise in maxillary
antrum & enter nasal cavity via osteum & pass backwards through posterior nares to form an
antro-choanal polyp
-radiological appearance
-occipito-mental view
Tumors
benign
ivory osteoma
inverted papilloma (from middle meatusof nose to the antrum)
fibrous dysplasia (ground glass radiolucent area with islands of
calcified bone)
ossifying fibroma
malignant
*Osteoma
-Features
common in frontal & rare in antrum &give symptoms when obstruct ostium
-Radiological appearance
-CT
*Carcinoma
-features
-late
Neuroradiology 93
________________________________________________________________________________________________
shows sites of bone destruction while Gd-MRI shows soft tissue spread
soft tissue mass with bone destruction
extension through cribriform plate to anterior cranial fossa (best seen by Gd-MRI)
extension into orbit (best seen by CT & Gd-MRI)
. invasion of infra-temporal fossa (may be seen before trisums becomes clinically evident best
seen by Gd-MRI) & pterygopalatine (middle cranial) fossa (best seen by CT)
evaluation of progress & response after raadiotherapy
Osteosarcoma
-radiological appearance
sinus is opaque
periosteal new bone formation
marked displacement of teeth
Sarcoidosis
-opacification of one or more sinus
-destruction of bone
-chest (postero-antrerior view)
Wegners granulomatosus
-generalised disease affects respiratory tract & kidney
-radiologically
Kartageners syndrome
-triad of
Blow-out fractures
-plain
-tomography
-CT
demonstrate fracture, bony fragments & herniation of orbital contents into the antrum
Neuroradiology 94
________________________________________________________________________________________________
-radiologically
1.exudate in mastoid air-cells
-radiological appearance may be normal,there may be bone destruction &large abscess cavity.
*Chronic otitis media & mastoiditis :- (see figure beside)
-classification
chronic suppurative
tubo-tympanic
labrynthitis obliterans
attico-antral
cholesteatoma
Neuroradiology 95
________________________________________________________________________________________________
nature carries a significant risk of complications & bone erosion in association with
cholesteatoma.
B)Chronic non supprative otitis media
Tuberculous otitis media
labyrinthites obliterans
-radiologically Stenvers view will show erosion of arch of lateral semicircular canal
by cholestestoma
b)venous sinus thrombophlebitis
-late phase of carotid angiogram may demonstrate obstruction of affected sinus
c)intracranial complications demonestrated by CT
-extradural & subdural abscess
-brain abscess which is usually in temporal lobe but may occur in cerebellum
-hydrocephalus
* Cholesteatoma :- definition the accumulation of keratin in a confined narrow space(skin bag in wrong lace
?epidermoid cyst ? bone infection)
- pathology the pesence of keratinzing stratified squamous epithelium in middle ear cleft with
desquamation of sheet of keratin & 2ry infection
enzymes
erosion of bone (medial attic wall & lateral spur & lateral attic wall as well)
destruction of ossicles
facial nerve paralysis
+
-etiology
Neuroradiology 96
________________________________________________________________________________________________
-associated features
-radiologically
-tomographic cuts
extent of pneumatization & position of sigmoid sinus & dural plates & signs may be :
1.an area of extensive bone erosion or destruction in attic or mastoid artrum associated
with smooth clear cut outline and little sclerosis around destructed bone.
2.mastoid process is usually sclerotic due to associated chronic infection (v.imp.)
3.with cellular mastoid there is extensive destruction of all walls however cholesteatoma
occurs mostly inpoorly or unpneumatised mastoid
- Tomographic changes
1.those affecting antrum
Neuroradiology 97
________________________________________________________________________________________________
keratin bag
CT
external auditory canal - ossicles & drum - semicircular canal & labyrinth
-Ct appearance of congenital & acquired cholesteatoma differs greatly from ragged
infiltrative lesions produced by other infective & neoplastic processes which tend to
affect labyrinth capsule at a very late stage
differential diagnosisd of cholesteatoma = differential diagnosis of destruction of petrous apex
1.Acoustic neuroma
2.congenital cholesteatoma
3.Naso-pharyngeal carcinoma
4.meningioma
5.Metastases particularly from breast, lung & kidney with irregular lytic defects + pain,
bleeding & nerve palsy
7.5th nerve neuroma (see figure beside)
8.Apical petrositis (Gradingo syndrome)
6.chordoma
trigeminal pain
6th nerve paralysis
mastoiditis
2.mostoid abscess
4.post operative
2.glomus jugular
3.metastases
4.tuberculosis
2.subdural
3.periantral
5.perisinus
6.tip
7.retro facial
4.sinodural
Neuroradiology 98
________________________________________________________________________________________________
(= chemodectomas = paragangliomas)
- Arise from glomus bodies (lies in top of jugular bulb & in middle ear) & include
glomus jugular, tympanicum from post ganglia of 8th nerve & vagal, carotid body tumor.
Glomus jugular
-Arises in roof of jugular fossa (floor of middle ear) to fill it & extends to middle ear &
posterior fossa & downwards to the neck
-clinical picture
conductive deafness
pulsating tinnitus
paralysis of cranial nerves (facial)
-CT
-MRI
2.venous phase
Neuroradiology 99
________________________________________________________________________________________________
123-
Diffusion MR
Diffusion is defined as the manner by which nutrients diffuse through capillary wall of cerebral
tissues. MRI was found to be an ideal method for investigating the diffusion of H2O by the possibility of
labeling its molecules by manipulating the magnetization of H+ proton.
Free diffusion is a process by which molecules move in a random fashion (incoherent intracellular
movement). In biological systems, totally free diffusion doesn't exist, instead we have restricted diffusion,
that is attributed to the presence of cell membranes and intracellular macromolecules. Therefore, water
motion is measured with a constant known as apparent diffusion coefficient (ADC) as opposed to a measure
of free diffusion.
In an ischemic cell, there is failure of the Na/K pump leading to intracellular influx of H 20. So the
net result is an in the intracellular content of H20 with a consequent in the sum of regional diffusional
movement of molecules.
So, in a normal cell, to obtain a DW Image:
If we have in a cell intracellular incoherent motion rephasing errors signal loss w is base of
a DWI. In normal situation: In DWI areas of the brain with less restricted diffusion of H 2O protons appears
dark and areas where diffusion is highly restricted appear bright.
However, on ADC images (calculated from DWI), the trend is reversed; areas of less restricted
diffusion appear bright & areas of restricted diffusion appear dark. In ischemic cells, we have increase in
intracellular H2O and decrease in sum of regional diffusion movement i.e. (which means) restricted
diffusion.
As a reflection of this restricted intracellular diffusion, in an ischemic cell, we have 33-66% decrease
in ADC within 1st hours, and as normally diffusion motion leads to signal loss, the ischemic areas having
less diffusion and consequently less signal loss, will have less signal loss than normal areas giving us higher
signal intensity on DWI as opposed to normal tissue (bright image).
In T2w image no differentiation can be made between restricted diffusion and highly restricted
diffusion areas. On the other hand, DW image and ADW image can help us in differentiation between acute
& chronic infarcts and in diagnosis of hyperacute stroke. Region of acute stroke is much better delineated in
DW image appearing as a hyperintense area and iIn ADW ischemic area are of low signal intensity.
Contribution of T2W versus DWI to final image contrast is determined by b value. We can have low
and high "b" value. To obtain a large b value we need MR machine with very high amplitude.
Neuroradiology 100
________________________________________________________________________________________________
Pefusion MR:
Perfusion is defined as the vascular process by which nutrients are delivered to the brain.
1st)
So far, most experiences have been gained with dynamic bolus studies using intravascular contrast.
2nd) In arterial spin techniques, blood is labeled by changing the state of its longitudinal magnetization e
RF
prepulses incorporated in imaging sequence. We use spin properties of H2O molecules, as an
endogenous indicator capable of passing blood brain barrier. These methods show the rCBV and provide
qualitative information on rCBF.
In dynamic bolus studies, 0.15-0.2 mmol/kg of Gd-DTPA I.V. (which is almost the standard dose) is
administered as quickly as possible (5-6 ml/s). Arterial spin labeling is a non-invasive technique, it allows
direct observation of rCBF. However, it necessitates a long acquisition time.
Used Pulse sequences for Diffusion Perfusion: the main drawback of old techniques, is their long acquisition
time increasing the chance of patient motion to which DWI is very sensitive. EPI is ccc by short acquisition
time of 30-100 ms by comparison for e.g. to larger turbo gradient acquisition time of 300 ms. So EPI can be
used in both diffusion perfusion imaging technique.
So less remember that infarcted area in DWI is bright and in ADW image it is dark.