Neurological Investigations

Lecture-15

Learning outcomes
Basic understanding of the commonly used neurological investigations. Basic interpretation of normal and abnormal pathologies/structures.

Normal CT of brain
Skull is intact Ventricles are normal sized grey versus white distinction is clear Midline is straight Sulci are symmetrical on both sides.

I-EXTRACRANIAL TISSUE

II-CRANIAL BONES

III-BLOOD

III-VENTRICULAR SYSTEM

IV-BRAIN TISSUE

V3

DILATED LV-NORMAL V3 & V4= OBSTRUCTIVE HYDROCEPHALUS BETWEEN LV & V3

LV

DILATED LV & V3+NORMAL V4 OBSTRUCTIVE HYDROCEPHALUS BETWEEN V3 & V4 AQUIDUCTAL STENOSIS

DILATED LV+V3+V4 COMMUNICATING HYDROCEPHALUS

DILATED SYLVIAN FISSURES=SAH

Severe brain trauma: nonhelmeted motorcycle rider

Epidural hematoma

Subarachnoid Hemorrhage
Blood shows white on CT. Anterior Communicating Artery aneurysm has burst, flooding the basal structures under the brain outside the brain parenchyma, but will occasionally empty into a Ventricle as it has on the left here (see fluid level). Note typical bat wing shape just above the mid-brain (green arrow).

Severe Subarachnoid Hemorrhage

Severe hemorrhage and probable clotting and obstruction causing hydrocephalus. Poor outcome Likely.

Acute subdural with contusion and edema on left side

Red arrow- acute blood between dura and brain. Green arrow- brain contusion with subarachnoid features. Edema shows as shift of midline toward right side.

Subdural hematoma

Chronic Subdural with new contusion on left parietal

If not resolved, acute subdural turns into chronic hygroma, consistency of crankcase oil and shows black (red arrow). New contusion with subarachnoid and parenchyma features shown by green arrow.

Intra cerebral haemorrhage

Midline shift

Big bland stroke on right and craniotomy for decompression

Other strokes progress to severe brain edema 3 - 5 days post stroke and require surgical decompression. Note cranium removed on right side to make room for brain edema. CT shows bland stroke as dark contrast. Temporal lobe is sometimes also removed on ipsalateral side to make room for edema. Humans can live normally with only one temporal lobe.

Stroke (post craniotomy for decompression)

Big bland stroke on left, with craniotomy and replacement of skull fragment (green arrow).

Intraparenchymal bleed into ventricles

infarction

Intraventricular bleed
This was a young person who eventually went on to rehab

Normal MRI
MRI shows alterations between water and fat content of tissues. Gives a high resolution view of brain, especially stroke, appearing as white contrast which sometimes can take as long as 8 hours to show up.

Strokes show up faster on MRI than CT

MRI and CT views of the same whole R. hemispherical infarct

Some very big strokes settle down and dont require surgical decompression. This man opens his eyes to verbal commands.

Same bleed into brain stem on CT (right) and MRI (left)

New stroke on T2 FLAIR

New strokes usually show up as white on T2.

shows accumulated blood

Blood shows white on T2 Flair Left). black on MPGR (Right),

Old stroke
Usually cystify and develop firm borders

Cerebral abscesses

Brain tumors: Glioblastoma Multiforme

Glios are rapid growing and cause death by brain compression.

Giant meningioma
Meningiomas are slow growing and have discrete borders. Most amenable to operative resection.

MRI Side views: Chiari malformation

Some believe cranium too small for brain, Others believe the foramen magnum is malformed. Symptoms of headache, ataxia and nystagmus with progressive pressure on brain stem.

Hydrocephalus

CT angio of giant unruptured MCA aneurysm

The end