Neuropathology

Emma Rose
Clinical Specialist Radiographer
Great Ormond Street Hospital
Learning Outcomes

Outline the imaging modalities used in

Neuroimaging

Outline common neuropathologies and discuss

the role of CT & MRI in their evaluation
How do we image the brain?
Skull Radiographs
What diagnostic value do they have?
Skeletal Surveys
NAI
Metabolic

NOT in trauma
Wormian
Bones - OI
”Pepperpot
Skull”

Multiple lytic
lesions

Multiple Myeloma
Ultrasound

Used in neonates
Transcranial
Allows assessment of brain before fontanelles
close
Used to detect haemorrhage and hydrocephalus
Angiography

Often considered “gold standard” for

vasculature but gives no detail of parenchyma
Diagnostic imaging can be converted straight to
intervention when required
Nuclear Medicine

Assesses brain function

Radioisotope injected
Looks at blood flow – highlights area of brain
with different blood flow levels
Useful for Alzheimer's research, epilepsy and
brain damage assessment
CT

Gold Standard for trauma

Easily accessible & available
Multiplanar reformatting
MRI

Best modality for details of brain parenchyma

Multiplanar acquisitions
Functional Sequences
 CT MRI
First choice in trauma First choice for neuroimaging

Advantages include: Advantages include:

Disadvantages include: Disadvantages include:

 CT
First choice in trauma
Advantages include:
• Faster, readily available
• Most sensitive modality for acute
haemorrhage – able to age the bleed
• Most sensitive modality for skull trauma
• Most sensitive modality for calcification
• Often used when contraindications prevent
MRI
• Less safety/patient cooperation issues
Disadvantages include:
• Ionising radiation dose
• Often poor resolution of posterior cranial
fossa and brain stem
• Poorer soft tissue detail than MR
• Contrast agent used in order for
vascular/soft tissue detail to be obtained
MRI
First choice for neuroimaging
Advantages include:
• Fabulous soft tissue detail
• Visualise vasculature without contrast agent
• DWI highly sensitive to early ischaemic
changes
• Shows perfusion information
• Shows the chemical structure of tissues
• Can obtain functional and structural data
Disadvantages include:
• Less sensitive to acute haemorrhage
• Less sensitive to calcification and bony
abnormalities
• Susceptibility artefacts from ‘MR safe’
hardware
• Safety issues
• Patient co-operation issues
Pathologies
 Acute Non-Acute
Trauma Neoplasm
Haemorrhages Neurological Diseases
Aneurysm Vascular Malformations
Raised ICP
Hydrocephalus
Infection
CVA
Trauma

Head Injury – most common cause of death &

disability in patients <40 years (NICE, 2014)

1.4 million people attend A&E each year with

head injury
Around 40% of these are under 15 years old
200,000 people admitted

Examples: Fall, RTC, Assault, Sports Injury….

NICE Clinical Guidelines
 Criteria for performing a CT head scan
 For adults who have sustained a head injury and have any of the
following risk factors, perform a CT head scan within 1 hour of the risk
factor being identified:
 GCS less than 13 on initial assessment in the Emergency Department
 GCS less than 15 at 2 hours after the injury on assessment in the Emergency
Department
 Suspected open or depressed skull fracture
 Any sign of basal skull fracture
 Post-traumatic seizure
 Focal neurological deficit
 More than 1 episode of vomiting

 A provisional written radiology report should be made available

within 1 hour of the scan being performed
Haemorrhage

CT can detect this pathology

4 main types
 Extradural
 Subdural
 Subarachnoid
 Intracerebral
Meninges
Extradural (Epidural) Haemorrhage
Extradural Haemorrhage

Usually associated with a skull #

Laceration of a dural artery (middle
meningeal) or a venous sinus
Blood collects between the skull and
the dura mater
‘Walk and die’
Extradural Haemorrhage - CT

Biconvex – lens shaped (lentiform)

– lemon
Hyperdense, sharply demarcated
Homogenous density
Mass effect
66% temperoparietal
Mixed density suggests active
bleeding
Subdural Haematoma
Subdural Haemorrhage

Accleration/Deceleration
Injuries

Trauma: falls in elderly

Blood collects between dura

& arachnoid matter
Subdural Haemorrhage - CT
 Depends on age of clot

 Crescentic/sickle shaped - banana

 Acute - Hyperdense extra axial

 Does not cross the midline

 Subacute – density drops, becomes isodense

 Chronic - hypodense

 Acute on chronic – mixed densities

Subarachnoid Haemorrhage
Neurological emergency

Intracranial aneurysm ~85%

Risk factors:
Hypertension
Smoking
Excessive alcohol consumption
Illicit drugs - cocaine
Subarachnoid Haemorrhage
Presentation:
Thunderclap headache
Worst headache of life
Nausea & Vomiting
Meningism – triad of symptoms:
 nuchal rigidity (neck stiffness)
 photophobia
 headache
Aneurysms & SAH
 85% of aneurysms found
on Circle of Willis
 30% multiplicity
 Most <7mm don’t rupture
but grow unpredictably
Subarachnoid Haemorrhage
Subarachnoid Haemorrhage

CT does not have 100% sensitivity

Negative CT = lumbar puncture & CSF analysis

CT angiography can confirm bleed

Cerebral angiography will be used pre-

embolisation treatment
What kind of bleed is
this?

What would cause

this?
 Subdural

Crescent Shape

Does not cross

the midline

Mass Effect

Acceleration/Deacceleration
injuries.
Torn Vein
Falls in Elderly
What kind of bleed is
this?

What would cause

this?
Extradural

Convex

Temporoparietal

Skull Fracture –
Meningeal Artery
What kind of bleed is
this?

What would cause

this?
Subarachnoid

Circle of Willis

Diffuse

Likely aneurysm
Recap: Haemorrhage
4 main types
 Extradural
 Subdural
 Subarachnoid
 Intracerebral
Pathologies

Acute Non-Acute
Trauma Neoplasm
Haemorrhages Neurological Diseases
Aneurysm Vascular Malformations
Raised ICP
Hydrocephalus
Infection
CVA
Raised Intracranial Pressure

What causes it?

Haemorrhage
Space Occupying Lesions
Oedema
Imaging Features
Effacement (obliteration) of the ventricles
Loss of GWM differentiation
Loss of gyri/sulci differentiation
Brain herniation
Raised Intracranial Pressure
Loss of
sulci/gyri

Loss of GWM
differentiation
Raised Intracranial Pressure
Hydrocephalus

Dilation of the ventricular system

Ventricular enlargement can cause compression
& consequently destruction of the surrounding
structures
Appearance on MR & CT are similar
MR may provide more information on the cause
of the hydrocephalus
Hydrocephalus
Hydrocephalus – Ventricular Shunts

Divert the CSF to another part of the body

Proximal catheter placed into the ventricles via burr
hole
Two types:
VA shunt – ventriculoatrial – distal catheter inserted
into left atrium
VP shunt – ventriculoperitoneal – distal catheter
inserted into the peritoneum (most common type)
Infection - Meningitis
 Acute inflammation of the meninges (dura, arachnoid and pia mater)
 Causes:
 Bacterial
 Viral
 Fungal (rare)
 Symptoms:
 Headache
 Fever
 General malaise
 Nausea & Vomiting
 Rash
 Meningism
Infection - Meningitis

Diagnosis:
CT usually to exclude contraindications for LP and
exclude other pathology – it is often a normal
scan
MRI most sensitive – detects inflammatory
changes in the meninges
Lumbar Puncture – CSF tested for pathogens
Infection - Meningitis
Cerebrovascular Accident (CVA)

Disruption to the blood supply to the brain

Usually caused by a blood clot – ischaemic stroke
Can be caused by bleeds – haemorrhagic stroke
Medical Emergency
Cerebrovascular Accident (CVA) -
Symptoms
Physical Problems on one side of body
(numbness/weakness)
Drooping on one side of face
Speech Problems (slurred speech, mixed up words)
Visual Problems (blurred vision, loss of vision)
Confusion
Severe Headache
Imaging of Stroke
Exclude a haemorrhage
Identify the presence of a structural lesion
Identify vessels
Identify damaged/normal brain tissue
CT can be normal <12 hours in around 60% of
cases
First Line = Non Contrast CT
CT perfusion done in specialist stroke centres for
hyperacute strokes
https://www.khanacademy.org/science/health-and-medicine/circulatory-system-
diseases/stroke/v/diagnosing-strokes-with-imaging-ct-mri-and-angiography
Is this a normal scan?

Not
symmetrical

Darker area =
hypodense

Patient
positioning
important
CT Perfusion
Pathologies

Acute Non-Acute
Trauma Neoplasm
Haemorrhages Neurological Diseases
Aneurysm Vascular Malformations
Raised ICP
Hydrocephalus
Infection
CVA
Neoplasm
Primary brain tumours cause 10% of deaths from
cancer
Can be benign or malignant
Location of tumour more important to prognosis
than if benign or malignant
Oedema will cause raised ICP and mass effect
Symptoms will depend on location of the tumour
Benign (or Low Grade I, II)
Relatively slow growing tumour
Less likely to come back if completely removed
Not likely to spread to other parts of brain or
spinal cord
May just need surgery and not
radiotherapy/chemotherapy as well
Some may re-grow at slow rate and need futher
surgery/radiotherapy
If tumour’s position means surrounding tissue
could be damaged by surgery then removal may
not be possible
Malignant (or High Grade III, IV)
Tumour is life-threatening and relatively fast
growing
Likely to come back after surgery, even if
completely removed
May spread to other parts of the brain or spinal
cord
Cannot just be treated with surgery. Will need
radiotherapy or chemotherapy to try and prevent
reoccurrence
Pituitary Adenoma
Acoustic Neuroma
Meningioma
Glioma – Astrocytoma
Metastases – 20% of all tumours metastasise to
the brain
Pituitary Adenoma
Benign tumours that affect mainly the anterior
lobe of the pituitary gland
Relatively common
Symptoms depend on where the lesion is in the
gland:
Disruption of hormones
Compression of surrounding structures such as optic
chiasm
Pituitary Adenoma
Acoustic Neuroma
Vestibular Schwannoma – made from Schwann
cells that line the 8th cranial nerve
Benign, usually slow growing
Symptoms include one sided hearing loss and
balance problems
MRI with Gad (contrast) = gold standard
Very high resolution images
Acoustic Neuroma
Acoustic Neuroma
Meningioma
Tumour of the meninges – arises from the
subarachnoid lining and attaches to the dura
 90% benign
Symptoms depend on location of the tumour and
are caused by brain displacement/compression by
the mass
Can calcify
Gliomas
Most common primary brain tumours
Arise from the Glial Cells:
Astrocytomas – from astrocytes
Ependymomas – from ependymal cells
Oligodendrogliomas – from oligodendrocytes
Intra-axial tumours (lesions within parenchyma)
Symptoms caused by tumour pressing on brain or
spinal cord
Brain Metastases
Arise from spread of primary tumour via blood to
the brain
Signs & Symptoms:
Change in cognitive ability
Behavioural changes
Gait ataxia
Visual & Speech Changes
Headaches
Seizures
Imaging Neoplasms
MRI:
Most sensitive T1 - Anatomy

High signal on T2
T2 – Pathology –
Low signal on T1 fluid high signal

Enhance with gadolinium

CT
Difficult to see without contrast unless oedema or
calcification present
Infiltration of bony structures
Epilepsy
Affects ~400,000 patients in UK (NICE, 2012)
Can have huge effect on lifestyle
Aim of imaging = to localise an epileptogenic
lesion
Causes include:
AVMs/tumours
Cortical dysplasia (structural abnormalities of the
cortex)
Hippocampal sclerosis
Imaging of Epilepsy
CT will show gross pathology that may explain
cause of seizure
MRI will show greater detail of specific lesions
Functional MRI measures the blood flow when
specific areas of the brain are working
PET and SPECT pinpoint locations in the brain
where the seizures orginate
Dementia
Imaging used to support clinical diagnosis
Aim of imaging is to rule out other pathology and
to distinguish type of dementia
MRI = modality of choice
Can assess degree/pattern of atrophy
Can look at diseased blood vessels (vascular
dementia)
Normal brain scan cannot exclude Alzheimer’s
CT of Dementia
Widened sulci
Small vessel disease – hypodensities usually
around the ventricles
Learning Outcomes

At the end of this session, you should be able to:

Outline the imaging modalities used in

Neuroimaging

Outline common neuropathologies and discuss

the role of CT & MRI in their evaluation