ICM Neuroradiology

Siri-on Tritrakarn, M.D.

Division of Diagnostic
Neuroradiology
 Contents
• Diagnostic tools
– Plain film
• Skull, Paranasal sinus, sellar tursica
• Spine : Cervical, Thoracic and Lumbar
– Computer Tomography (CT scan)
– Magnetic Resonance Imaging (MRI)
– Myelography
– Angiography

• Contrast media
 Diagnostic Tools
• Non-invasive techniques
– Plain film
– Computed Tomography (CT)
– Magnetic Resonance Imaging (MRI)

• Invasive techniques
– Angiography
– Myelography
Plain radiography
 Advantage & I/C
• Advantage • Indication
- Convenience - Fracture skull
- Safe - Osteolytic/
- Fast osteoblastic lesion
- Availability - Intrasellar mass
- Increase ICP
- Calcifying pathology
 Plain films

• Views and positionings

• Basic anatomy
 5 densities in radiology
1. Air 4
2. Fat 2,3
3. Soft tissue
(water,muscles,etc)
4. Bone, calcification
1
5. Metallic
5
Plain film Spine
cervical
thoracic
lumbar
Principle in interpretation
of spines
• Anatomy
• Alignment
• Body homogenity
• Curvature, canal
• Density/disc
 Curvature
•C- spine:
Lordosis
•T-spine:
Kyphosis
•L-spine:
 Cervical spine

AP LATERAL OBLIQUE
 Thoracic spine

LATERAL AP
 Lumbar spine

AP LATERAL OBLIQUE
 Abnormal Conditions of Spine

• Fracture
• Degenerative changes
• Metastasis
• Infection
• Underlying hematologic conditions:
Multiple myeloma, leukemia, lymphoma,
Thalassemia
CT SCAN OF LUMBAR SPINE

Axial

coronal Sagittal
 Computer
Tomography
Spiral CT or MDCT
 Computer Tomography :
CT scan
• Advantage
- Axial imaging
- Reconstruction, reformatted to coronal, sagittal
planes
- Providing contrast and non-contrast study
- Differentiation tissues by densities (HU)
- Additional software: CTA, CTV, 3D, CTP etc.
 Indication for CT scan
• Trauma case
• 1st line imaging of Stroke
• Infection
• Tumor
• Intracranial calcification
• Contraindication
– Pregnancy due to radiation exposure
– Allergy to contrast media
– Renal insufficiency (creatinine more than 2 mg/dl)
Density of tissue in HU.
 Attenuation number of CT (HU)
Hounsfield Units
• Air = >- 600 HU.
• Fat = -100-200 HU.

• CSF = 0-20 HU.

• White matter = 23-46 H
• Gray matter = 40 HU.
• Clot blood & hematoma = 60-90 HU.
• Calcification and bone = +100-200 HU.

• Density ของ lesion ใดๆจะดู เทียบกับ gray matter

: hypodensity, isodensity and hyperdensity
What is hyperdensity on
CT scan?
• Calcification
• Hemorrhage
• Metallic (very
dense)
 Hypodensity lesion at right frontotemporal lobe :
Right Middle cerebral artery territory Infarction

Hypodensity lesion
Isodensity lesion : Subacute stage
of subdural hematoma

Isodensity lesion Post contrast : well defined margin

 Intracerebral hemorrhage
(Brain contusion)
• Occurred near bony ridge
such as temporal tip,
inferior surface of brain
and near sylvian

CT findings :
• Ill-defined low density at
brain parenchyma
• +/- petechial hemorrhage
• Edema increase in first
2-3 days
 HT hemorrhage at right basal ganglia with rupture
into ventricular system cause intraventricular
hemorrhage and obstructive hydrocephalus from
blood clot

Hyperdensity lesion
 MRI
• Magnetic Field (usually used) : 1.5-3 Tesla
 Advantage MRI
1. Multiplanar imaging
( axial/coronal/sagittal/any planar)
1. No radiation
2. No bony artifact
3. Less allergic to contrast agent (Gadolinium)
4. Best for analysis: posterior fossa and
leptomeningeal lesions
5. Best for tissue differentiation : gray and white
matter lesion
 DisadvantageMRI
Disadvantage
• Consume time
• Disadvantage for evaluated calcification
and bone
• Need patient cooperation and stable vital
sign
• Artifact from metallic
 Contraindications
• Implantation of Cardiac defibrillator
• Cardiac pace Maker
• Weight. > 136 Kg
• Severe Claustrophobia
• Pregnancy (+/- )
• Cochlear Implantation
• Aneurysm Clips
• Ferromagnetic eye prosthesis / F.B.
 T2W
-CSF cleft
-Grey-white
buckling

Meningioma

T1W

T1W+Gd
 Vascular diagram
MCA ACA
PCA

Terminal ICA
Basilar a.
MRA : MR angiography : coronal view
Digital Subtraction
Angiography
(DSA)
ANGIOGRAM – MCA BIFURCATION ANEURYSM
 MCA aneurysm

CTA DSA
Left MCA aneurysm

36
 Indication

• Gold standard for vascular imaging

Arterial / venous system for diagnosis
and treatment
( ex. Aneurysm, AVM)
• Risk=1%
• C/I : azotemia, pregnancy due to use
contrast media and radiation exposure
 Myelography
• For evaluated subarachnoid space in
spinal canal by using contrast media

• Contraindication :
– Lumbar puncture < 7 days
– Allergic to contrast media
– Infection at skin
– Lumbar pain without neurological
symptom
Myelography : Intramedullary tumors

Enlargement of cord

Symetrical narrowing paraspinal gutter

 Contrast medium

• General precaution
– Hx: allergic to iodine, contrast medium,
seafood allergy
– Hx: allergic and asthma
– Creatinine > 2 mg/dl