Neuroradiology

Dr. Grant J. Linnell

Fellow
Montreal Neurological Hospital
McGill University
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 CT Basics
• No disclosures
 Neuroradiologist
• A consultant in imaging and disease of the
brain, spinal cord, head, neck, face and
peripheral nerves
 Neuroradiology
• Plain Film
• CT
• US
• MRI
• Interventional
– Angiography
– Myelography
– Biopsy
• Nuclear Medicine
 Neuroradiology
• A request for an exam is a consultation
– History
– Pertinent physical exam findings
• Lab results
– Creatinine
– PT/INR

– What is the question?

 CT Basics
• Computed tomography (CT)
• Computed axial tomography or computer –
assisted tomography (CAT)
CT Basics
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 CT History
• Electro-Musical Instruments
 CT History

SIR GODFREY N. HOUNSFIELD

• 1979 Nobel Laureate
in Medicine
 CT History
• 1972 – First clinical CT scanner
– Used for head examinations
– Water bath required
– 80 x 80 matrix
– 4 minutes per revolution
– 1 image per revolution
– 8 levels of grey
– Overnight image reconstruction
 CT History
• 2004 – 64 slice scanner
– 1024 x 1024 matrix
– 0.33s per revolution
– 64 images per revolution
– 0.4mm slice thickness
– 20 images reconstructed/second
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 CT Protocolling
• What happens when an exam is requested?
– A requisiton is completed.
– The requested exam is protocolled according to history,
physical exam and previous exams.
– The patient information is confirmed.
– The exam is then performed.
– Images are ready to be interpreted in …
• Uncomplicated exam – 5-10 minutes after completion
• Complicated exams with reconstructions take at least 1 hour
but usually 1-2 hours.
 CT Protocolling
• CT head protocols
– With or Without contrast
– CT Brain
– CT Brain with posterior fossa images
– CT Angiogram/Venogram
– CT Perfusion
– CT of Sinuses
– CT of Orbit
– CT of Temporal bones
– CT of Mastoid bones
– CT of Skull
– CT of Face
 CT Protocolling
• Variables
– Plain or contrast enhanced
– Slice positioning
– Slice thickness
– Slice orientation
– Slice spacing and overlap
– Timing of imaging and contrast administration
– Reconstruction algorhithm
– Radiation dosimetry
 CT Protocolling
• Patient Information
– Is the patient pregnant?
• Radiation safety
– Can the patient cooperate for the exam?
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases (Stroke)
 CT Terminology
• Exams using Ionizing radiation
– Plain film
– CT
• 1/10 of all exams
• 2/3 OF RADIATION EXPOSURE
– Fluoroscopy
• Angiography, barium studies
– Nuclear medicine
• V/Q scan, bone scan
 CT Terminology
• Attenuation
– Hyperattenuating (hyperdense)
– Hypoattenuating (hypodense)
– Isoattenuating (isodense)
• Attenuation is measured in Hounsfield units
– Scale -1000 to 1000
• -1000 is air
• 0 is water
• 1000 is cortical bone
 CT Terminology
• What we can see
– The brain is grey
• White matter is usually dark grey (40)
• Grey matter is usually light grey (45)
• CSF is black (0)
• Things that are brite on CT
– Bone or calcification (>300)
– Contrast
– Hemorrhage (Acute ~ 70)
– Hypercellular masses
– Metallic foreign bodies
 CT Terminology
• Voxel
– Volume element
• A voxel is the 2 dimensional representation of a 3
dimensional pixel (picture element).
– Partial volume averaging
CT Terminology
 CT Terminology
• Window Width
– Number of Hounsfield units from black to
white
• Level or Center
– Hounsfield unit approximating mid-gray
CT Terminology
CT Artifacts
 CT Terminology
• Digital reading stations are the standard of
care in interpretation of CT and MRI.
• Why?
– Volume of images
– Ability to manipulate and reconstruct images
– Cost
 CT Terminology
• DICOM
– Digital Imaging and Communications in
Medicine
– DICOM provides standardized formats for
images, a common information model,
application service definitions, and protocols
for communication.
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 Contrast
• Barium
• Iodinated
– vascular
– Biliary, Urinary
– CSF
• Gadolinium
Contrast
 Contrast
• Types of iodinated contrast
– Ionic
– Nonionic - standard of care
• No change in death rate from reaction but number of
reactions is decreased by factor of 4.
• If an enhanced study is needed, patient
needs to be NPO at least 4 hours and have
no contraindication to contrast, ie allergy or
renal insufficiency.
 Contrast
• What are the risks of iodinated contrast?
– Contrast reaction
• 1 in 10,000 have true anaphylactic reaction
• 1 in 100,000 to 1 in 1,000,000 will die
– Medical Issues
• Acute renal failure
• Lactic acidosis in diabetics
» If on Glucophage, patient must stop Glucophage for
48 hours after exam to prevent serious lactic acidosis
• Cardiac
– Extravasation
 Contrast
• Who is at risk for an anaphylactic reaction?
– Patients with a prior history of contrast reaction
– Patients with a history asthma react at a rate of
1 in 2,000
– Patients with multiple environmental allergies,
ie foods, hay fever, medications
Amin MM, et al. Ionic and nonionic contrast media: Current status and
controversies.

Appl Radiol 1993; 22: 41-54.

 Contrast
• Pretreatment for anaphylaxis
– 50 mg Oral Prednisone 13, 7 and 1 hour prior to
exam
– 50 mg oral Benedryl 1 hour prior to exam
– In emergency, 200 mg iv hydrocortisone 2-4
hours prior to exam
 Contrast
• What are the risk factors for contrast
induced acute renal failure?
– Pre-existing renal insufficiency
– Contrast volume
– Dehydration
– Advanced age
– Drugs
– Multiple myeloma
– Cardiac failure
 Contrast
• Considerations in patients with renal
insufficiency
– Is the exam necessary?
– Is there an alternative exam that can answer the
question?
– Decrease contrast dose
 Contrast
• Pretreatment for renal insufficiency
– Hydration
– Mucomyst
• 600 mg po BID the day before and day of study

Prevention of radiographic-contrast-agent-induced reductions in renal function by

acetylcysteine.
Tepel M, et al. N Engl J Med 2000 Jul 20;343(3):180-4
 Contrast
• Contrast induced renal failure
– Elevated creatinine 24-48 hours after contrast
which resolves over 7-21 days.
– Can require dialysis

Mehran, R. et al. Radiocontrast induced renal failure:Allocations and outcomes.

Reviews in Cardiovascular Medicine Vol. 2 Supp. 1 2001

 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
 Radiation Safety
• Diagnostic CT Scans: Assessment of
Patient, Physician, and Radiologist
Awareness of Radiation Dose and Possible
Risks
– Lee, C. et al. Radiology 2004;231:393
 Radiation Safety
• Deterministic Effects
– Have a threshold below which no effect will be
seen.
• Stochastic Effects
– Have no threshold and the effects are based on
the dose x quality factor.
 Radiation Safety
• Terminology
– Gy = Gray is the absorbed dose (SI unit)
• The equivalent of 1 joule/kg of tissue
• Rad = radiation absorbed dose
– Sv = Sievert is the dose equivalent (SI unit)
• Absorbed dose multiplied by a quality factor
• Rem = radiation equivalent man
 Radiation Safety
• Relative values of CT exam exposure
– Background radiation is 3 mSv/year
• Water, food, air, solar
• In Denver (altitude 5280 ft.) 10 mSv/year
– CXR = 0.1 mSv
– CT head = 2 mSv
– CT Chest = 8 mSv
– CT Abdomen and Pelvis = 20 mSv
-The equivalent of 200 CXR
 Radiation Safety
• Effects of X rays.
– Absorption of photons by biological material
leads to breakage of chemical bonds.
– The principal biological effect results from
damage to DNA caused by either the direct
or indirect action of radiation.
 Radiation Safety
• Tissue/Organ radiosensitivity
– Fetal cells
– Lymphoid and hematopoietic tissues;
intestinal epithelium
– Epidermal, esophageal, oropharyngeal
epithelia
– Interstitial connective tissue, fine vasculature
– Renal, hepatic, and pancreatic tissue
– Muscle and neuronal tissue
 Radiation Safety
• Estimated Risks of Radiation-Induced Fatal
Cancer from Pediatric CT
– David J. Brenner, et al. AJR 2001; 176:289-296
• Additional 170 cancer deaths for each year of head CT in
the US.
– 140,000 total cancer deaths, therefore ~ 0.12% increase
– 1 in 1500 will die from radiologically induced cancer
 Radiation Safety
• 3094 men received radiation for
hemangioma
– Those receiving >100 mGy
– Decreased high school attendance
– Lower cognitive test scores

Per Hall, et al. Effect of low doses of ionising radiation in infancy on cognitive
function in adulthood: Swedish population based cohort study
BMJ, Jan 2004; 328: 19 - 0.
 Radiation Safety
• Hiroshima and Nagasaki
– There has been no detectable increase in
genetic defects related to radiation in a large
sample (80,000) of survivor offspring,
including: congenital abnormalities, mortality
(including childhood cancers), chromosome
aberrations, or mutations in biochemically
identifiable genes.
William J Schull, Effects of Atomic Radiation: A Half-Century of Studies from
Hiroshima and Nagasaki, 1995.
 Radiation Safety
• Hiroshima and Nagasaki
– However, exposed individuals who survived the
acute effects were later found to suffer
increased incidence of cancer of essentially all
organs.

William J Schull, Effects of Atomic Radiation: A Half-Century of Studies from

Hiroshima and Nagasaki, 1995.
 Radiation Safety
• Hiroshima and Nagasaki
– Most victims with high doses died
– Victims with low doses despite their large
numbers are still statistically insignificant.
Radiation Safety
Comparison of Image Quality
Between Conventional and Low-
Dose Nonenhanced Head CT
Mark E. Mullinsa, et al.
AJNR April 2004.

Reduction of mAs from 170 to 90

 Radiation Safety
• What does all this mean?
– 1 CXR approximates the same risk as:
• 1 year watching TV (CRT)
• 1 coast to coast airplane flight
• 3 puffs on a cigarette
• 2 days living in Denver
– 1 Head CT is approximately 20 CXR

Health Physics Society on the web--http://hps.org

 Radiation Safety
• The pregnant patient
– Can another exam answer the question?
– What is the gestational age?
– Counsel the patient
• 3% of all deliveries have some type of spontaneous
abnormality
• The mother’s health is the primary concern.
 Radiation Safety
• "No single diagnostic procedure results in a radiation dose
that threatens the well-being of the developing embryo and
fetus." -- American College of Radiology
• "Women should be counseled that x-ray exposure from a
single diagnostic procedure does not result in harmful fetal
effects. Specifically, exposure to less than 5 rad has not
been associated with an increase in fetal anomalies or
pregnancy loss." -- American College of Obstetricians and Gynecologists
 Conclusion
• Neuroradiologists are consultants
• Garbage in ------- Garbage out
• CT Terminology
– Attenuation (density) in Hounsfield units
– Digital interpretation is standard of care
• CT has risks
– Contrast
– Radiation exposure
 CT Basics
• Neuroradiology
• The BASICS of CT
– CT History
– Protocol
– Terminology
– Contrast
– Radiation Safety
– Cases
Normal
CT
1 day 1 year 2 years
Normal CT
Older person
Normal Enhanced CT
 Case 1
• 55 yo female with sudden onset of worst
headache of life
Case 1
Case 1
 Case 1
• What do I do now?
CTA
Normal Angiography
Diagnostic Angiography
 Case 1
• Subarachnoid Hemorrhage
– Most common cause is trauma
– Aneurysm
– Vascular malformation
– Tumor
– Meningitis
– Generally a younger age group
 Case 2
• 82 yo male with mental status change after
a fall
Case 2
 Case 2
• Subdural hematoma
• Venous bleeding from bridging veins
• General presentation
– Older age group
– Mental status change after fall
– 50% have no trauma history
Subdural Hematoma
 Case 3
• 44 yo female with right sided weakness and
inability to speak
Case 3
 Case 3
• Acute ischemic left MCA stroke
 MCA Stroke
“Dense MCA”
 Case 4
• 50 yo male post head trauma.
• Pt was initially conscious but now 3 hours
post trauma has had a sudden decrease in
his neurological function.
Case 4
 Case 4
• Epidural hematoma
– Typical history is a patient with head trauma
who has a period of lucidity after trauma but
then deteriorates rapidly.
– Hemorrhage is a result of a tear through a
meningeal artery.
 Case 5
• 71 yo male who initially complained of
incoordination of his left hand and
subsequently collapsed
Case 5
 Case 5
• Intraparenchymal hemorrhage
– Hypertensive
– Amyloid angiopathy
– Tumor
– Trauma
 Case 6
• 62 yo female acute onset headache
– Hemiplegic on the right and unable to speak
 Case 6
• Add htn image here
 Case 6
• Hypertensive hemorrhage
– Clinically looks like a large MCA stroke
– Generally younger than amyloid angiopathy
patients
Chronic Ischemic change =
Encephalomalacia
 Thrombolysis:
• Intravenous
– 3 hours
• Intra-arterial
– 6 hours ICA territory
– 24 hours basilar territory
• CT head plain shows no established stroke
nor hemorrhage
• CT perfusion shows a salvagable penumbra
 Case 7
• 53 y.o. male
• Sudden onset of ataxia loss of
consciousness proceeding rapidly to coma
 Case 7
• Probable basilar occlusion with cerebellar
and brainstem infarction
 Case 8
• 52 yo male with right sided weakness
Case 8
Case 8
 Case 8
• Acute lacunar infarction
– Cannot reliably differentiate this finding on CT
from remote lacune without clinical correlation.
– MRI with diffusion is the GOLD STANDARD
– A word on TIA
Chronic Small Vessel Disease
 Case 9
• 59 yo female with multiple falls over last
weekend
Case 9
 Case 9
• Stroke involving caudate head, anterior
limb internal capsule and anterior putamen.

• What is the artery?

• Recurrent artery of Heubner

 Case 10
• 42 yo male found in coma
Case 10
 Case 10
• Global ischemia
Angiographic Brain Death
 Case 11
• 24 yo male with siezures
Case 11
 Case 11
• Heterotopia
 Case 12

• 34 y.o. female
• Severe H/A,nausea
• Taking oral contraceptives
Case 12
Case 12
 Case 12
• Transverse sinus thrombosis