Principios de Imagenologa Neurolgica

Daniel Aguirre Fernndez MD

 Temas a revisar
Tomografa simple de crneo (TC):

Generalidades

Recuento anatmico

ECV isqumico y hemorrgico

Resonancia Magntica Cerebral (MRI):

Diferenciacin T1, T2, FLAIR, DWI

Indicaciones

Casos clnicos representativos

Daniel Aguirre Fernndez
 PARA REALIZAR UN DIAGNSTICO
BASADO EN UNA IMAGEN ES
IMPRESCINDIBLE CONOCER EL CUADRO
CLNICO DEL PACIENTE

Daniel Aguirre Fernndez

INTRODUCTION TO
BRAIN IMAGING

Michael S. Gordon
Center for Research in Medical Education

MILLER
SCHOOL OF MEDICINE
UNIVERSITY OF MIAMI
 INTRODUCTION TO BRAIN IMAGING:
OBJECTIVES
Distinguish normal and abnormal CT & MRI scans of the brain
and identify mass lesion, ischemia, and hemorrhage;
Identify neurologic structures on brain CT & MRI scans, including:
Brainstem (medulla, pons, and midbrain) and cerebellum
CSF structures: all 4 ventricles, Sylvian aqueduct, quadrigeminal plate
cistern, perimesencephalic cistern, suprasellar cistern, Sylvian fissure,
interhemispheric fissure
Deep white matter: corpus callosum, internal capsule, corona radiata,
and centrum semiovale
Subcortical gray matter: thalamus, lentiform nucleus (globus pallidus
and putamen), caudate nucleus
Cortex: frontal, parietal, temporal, and occipital lobes; insula
Arteries: circle of Willis and arterial branches (middle cerebral, anterior
cerebral, posterior cerebral arteries)

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COMPUTED TOMOGRAPHY
(CT) SCAN OF THE BRAIN:
INTRODUCTION

Detects acute blood, major cerebral

structures
Optimal test for suspected:
head trauma
acute stroke
cerebral herniation
Fair sensitivity for parenchymal disease
Bony artifact interferes w/ visualization of:
posterior fossa (brainstem, cerebellum)
inferior temporal lobes

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 Artefacto de
movimiento

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 Artefacto
seo

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 THINGS THAT ARE WHITE
(HYPERDENSE) ON A CT SCAN
ocular lens bone contrast (dye)

calcifications acute blood metal (bullets w/

streak artifact)
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DENSIDADES DE LOS TEJIDOS

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Calcificaciones

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CALCIFICACIONES
Calcificaciones intracraneales son de dos tipos:
Fisiolgicas y Patolgicas.
Fisiolgicas:
Plexos coroideos.
Glndula Pineal, es normal despus de los 20
aos, si aparece antes de los 12 aos sugiere
proceso patolgico de la pineal.
Habnula localizada por delante de la pineal.
Ligamentos petroclinoideos e interclinoideos.
Ganglios basales
Cristalino.
Calcificacin de la duramadre, hoz del cerebro.

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CALCIFICACIONES (placa sin contraste)

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CALCIFICACIONES

Patolgicas:
Tuberculosis.
Toxoplasmosis
Cisticercosis
Enf. Por inclusin de citomegalovirus.
Esclerosis tuberosa. O enf. de Bourneville.
Calcificacin de las MAV.
Tumores cerebrales
Absceso cerebral.
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DENSIDADES DE LOS TEJIDOS

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THINGS THAT ARE BLACK
(HYPODENSE) ON A CT SCAN

fat

air

CSF = water

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THINGS THAT ARE BLACK
(HYPODENSE) ON A CT SCAN

CSF is black
Lesions are dark
edema
water
infarction
gliosis
chronic blood

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 THINGS THAT ARE GRAY
(ISODENSE) ON A CT SCAN
Note that white
matter is less dense than
gray matter and therefore:
white matter is darker
than gray matter
Gray matter (cerebral cortex)

Gray matter (basal ganglia)

White matter

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WWW.GCRME.MIAMI.EDU Daniel Aguirre Fernndez
TIPOS DE CORTES

Coronal

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TIPOS DE CORTES

Sagital

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TIPOS DE CORTES

Axial

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CT SCAN OF THE BRAIN:
AXIAL VIEW IS MOST COMMON
Anterior

Right Left

Posterior
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 BRAIN CT: ANATOMY 1
Nose
Eye
Sphenoid bone
Temporal lobe
Clivus
Petrous bone
Mastoid air cells
Pons
Cerebellum

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 BRAIN CT: ANATOMY 2
Eye Sella turcica
Optic nerve Dorsum sellae
Lateral rectus Petrous bone
Medial rectus Mastoid air cells
Sphenoid bone Pons
Temporal lobe Brachium pontis
4th ventricle
Cerebellum

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 BRAIN CT: ANATOMY 3
Frontal sinus
Orbit
Frontal lobe
Sylvian fissure
Carotid artery
Temporal lobe
Suprasellar cistern
Perimesencephalic cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum

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 BRAIN CT: ANATOMY 4
Frontal lobe
Interhemispheric fissure
Sylvian fissure
Middle cerebral artery
Temporal lobe
Lateral ventricle (temporal horn)
Posterior cerebral artery
Suprasellar cistern
Perimesencephalic cistern
Interpeduncular cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum (vermis)
Occipital lobe
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 BRAIN CT: ANATOMY 5
Frontal lobe
Interhemispheric fissure
Sylvian fissure
Third ventricle
Temporal lobe
Lateral ventricle (temporal horn)
Sylvian aqueduct
Cerebellum (vermis)
Occipital lobe
Falx

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 BRAIN CT: ANATOMY 6
Frontal lobe
Lateral ventricle (frontal horn)
Caudate nucleus (head)
Sylvian fissure
Insula (cortex)
External capsule
Lentiform nucleus
Internal capsule (post. Limb)
Thalamus
Temporal lobe
Pineal gland (calcified)
Lateral ventricle (atrium)
Choroid plexus (calcified)
Occipital lobe
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 BRAIN CT: ANATOMY 7
Frontal lobe
Interhemispheric fissure
Corpus callosum (genu)
Caudate nucleus (head)
Lateral ventricle (body)
Thalamus/choroid plexus
Corona radiata (white matter)
Parietal lobe
Occipital lobe
Falx

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 BRAIN CT: ANATOMY 8
Frontal lobe
Interhemispheric fissure
Corpus callosum (genu)
Caudate nucleus (body)
Lateral ventricle (body)
Corona radiata (white matter)
Parietal lobe
Falx

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 BRAIN CT: ANATOMY 9

Frontal lobe
Interhemispheric fissure and falx
Centrum semiovale (white matter)
Parietal lobe

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 Descripcin correcta

Corte (axial, sagital, coronal) de una (TC, MRI-

T1/T2/FLAIR/DW), con/sin colapso de ventrculos, con/sin
desviacin de lnea media (direccin), donde se observa
imagen hipo/hiper-densa/intensa compatible con (lesin
isqumica en territorio de ACM/ACA/ACP hemorrgica).

Daniel Aguirre Fernndez

 Concepto: Desviacin de lnea media

INDICA EFECTO DE MASA SUBYACENTE

RETRACCION DE PARENQUIMA CIRCUNDANTE

No hay desviacin
No hay desviacin
Daniel Aguirre Fernndez
Concepto: Desviacin de lnea media

S hay desviacin!!

Daniel Aguirre Fernndez

NONCONTRAST CT SCAN:

Description

Acute blood is white

(hyperdense)
and is within the brain
parenchymain this
case, the right thalamus

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NONCONTRAST CT SCAN:

Description

Acute blood is white

(hyperdense) around
the brain in the
subarachnoid space,
in this case in the:
basal cisterns &
4th ventricle

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 NONCONTRAST CT SCAN:
ECVI (4 HOURS)

Normal
gray-white Large, acute
junction MCA-territory
(distinct infarction with:
ribbon of
1) blurring of
cortical
gray matter) gray-white
junction &
2) sulcal
effacement
Normal
sulcus

R Description L Description

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 NONCONTRAST CT SCAN:
ECVI (4 DAYS)

Subacute infarction is
dark (hypodense)
with mass effect
(note: this is cytotoxic edema,
Normal occurring 2-5 days after
lateral ischemia & affecting both gray
and white matter)
ventricle

Compressed
lateral
ventricle

R Description L Description

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CT SCAN OF THE BRAIN
ARTERIAL TERRITORIES
ACA
MCA

AChA
PCA

Middle cerebral artery Posterior cerebral artery

Anterior cerebral artery Anterior choroidal artery

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 1

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Daniel Aguirre Fernndez
CT SCAN OF THE BRAIN
ARTERIAL PATTERN 1
Medial cortex
Description

Subacute infarction in proximal ACA territory

involving medial cortex (frontal); proximal ACA
occlusions involve the frontal lobe +/- parietal lobe;
more-distal ACA occlusions involve only parietal lobe

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 2

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 2

Description Subcortex

Lateral
Cortex

Subacute infarction in distal MCA territory

involving cortex and sparing subcortex;
this pattern is often due to distal MCA
occlusion by a cardioembolus

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 3

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 3

Description

Thalamus

Occipital lobe

Subacute infarction in proximal PCA territory

involving both thalamus and occipital lobe;
note that a distal PCA occlusion spares the thalamus

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 4

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 4

Description R L ACA-MCA
watershed

PCA-MCA
watershed

Infarctions in watershed territories (arrows);

in this case, L > R (with concurrent left LMCA infarction
outlined in red) due to hypotension in patient
with LICA occlusion and RICA stenosis

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CT SCAN OF THE BRAIN
ARTERIAL PATTERN 5

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 CT SCAN OF THE BRAIN
ARTERIAL PATTERN 5

Description

Subcortex

Infarction in lenticulostriate (MCA perforator) territory

in subcortical white matter, in this case, corona radiata; small-artery
infarctions may be due to small-artery disease or any embolic
source, including large-artery or cardiac sources

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NONCONTRAST CT SCAN:

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NONCONTRAST CT SCAN:

Abscess (vague ring)

Mass effect (compressed ventricle)

Mass effect (R-to-L shift

= subfalcine herniation)

Vasogenic edema
(due to mass lesions, e.g., abscess,
tumor; represents blood-brain barrier
disruption; involves only white matter)

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CONTRAST CT SCAN:

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CONTRAST CT SCAN:

Abscess (ring enhancement)

Note that the mass lesion is

more clearly defined
(called ring enhancement).
Enhancement with contrast
is due to leakage of dye
around the lesion
and occurs as a result of
blood-brain barrier disruption.

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NONCONTRAST CT SCAN

SDH chronic component

SDH subacute component

Subdural hematomas (SDHs) layer

concave to the brain like a crescent.
Although acute blood is white,
subacute blood (days to wks) is gray
& chronic blood (wks to mos) is black.
Since subacute SDHs are isodense
with brain parenchyma, they may be
hard to detect: look for sulcal
effacement & cerebral cortex that is
buckled and does not
extend to the skull.

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 MRI
Daniel Aguirre Fernndez
 Descripcin correcta

Corte (axial, sagital, coronal) de una (TC, MRI-

T1/T2/FLAIR/DW), con/sin colapso de ventrculos,
con/sin desviacin de lnea media (direccin), donde
se observa imagen hipo/hiper-densa/intensa
compatible con (lesin isqumica/hemorrgica en
territorio de ACM/ACA/ACP).

Daniel Aguirre Fernndez

 MAGNETIC RESONANCE IMAGING
(MRI) SCAN OF THE BRAIN:
INTRODUCTION

MRI advantages over CT

Detects ischemic changes within minutes (DWI MRI)
More sensitive for infarcts & older blood
Superior visualization of brainstem, inferior temporal lobe
Gives information about flow in vessels
T2*GRE MRI detects blood as well as CT (in past, MRI
felt to be inferior to CT for detecting acute blood)

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 THREE MAIN
CATEGORIES OF MRI
Spin Echo (SE) parenchyma, lesions
T1 weighted, T2 weighted, FLAIR
Echo Planar (EP) acute ischemia
diffusion weighted imaging (DWI)
Gradient Recall Echo (GRE or GRASS) flow, hemorrhage

FLAIR DWI GRE = GRASS

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SPIN ECHO (SE):
T1-WEIGHTED IMAGES
CSF is black
Lesions are dark
edema
water
acute infarction
gliosis
Lesions poorly seen without IV
contrast (gadolinium)
Best used for pre- & post-
gadolinium comparisons
Ca++ & bone black

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MRI-T1

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TC vs MRI-T1

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 SPIN ECHO (SE):
T2-WEIGHTED IMAGES
Click on label to make arrows appear and disappear

CSF is white Gliosis from

Lesions are white old infarcts
edema
water
acute infarction
gliosis
Lesions well seen
May be difficult to distinguish
lesion and CSF
Cannot distinguish new and old
lesions
Ca++ & bone black Pt X

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MRI-T2

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MRI-T1 vs MRI-T2

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SPIN ECHO (SE):
FLAIR (INVERSION RECOVERY)
Click on label to make arrows appear and disappear

CSF is black Gliosis from

old infarcts
standing water is black,
including old lacunes
Lesions are white
edema
acute infarction
gliosis
Lesions very well seen
Cannot distinguish new
and old lesions
Ca++ & bone black

Pt X

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MRI-FLAIR

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MRI-T1 vs MRI-FLAIR

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MRI-T2 vs MRI-FLAIR

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MRI T1 vs MRI-T2 vs MRI-
FLAIR

Daniel Aguirre Fernndez

 ECHO PLANAR (EP): To CT menu
DIFFUSION-WEIGHTED IMAGING (DWI)
Click on label to make arrow appear and disappear To MRI menu

CSF black New infarct

New infarctions are white
30 min to few wks
Old lesions not seen
Compare to T2 or FLAIR to
distinguish new & old lesions
Only takes a minute

May show lesions due to other

conditions as a result of T2-shine-
through phenomenon (corrected Pt X
by correlating w/ ADC image)

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MRI-DW

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TC vs MRI-DW

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Patologas

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Stroke Isqumico

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Stroke Hemorrgico

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Otras Patologas

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