NEUROIMAGISTICA

CURS

Brain Imaging

Static : Anatomical identify brain structures

Was the frontal cortex damaged by the stroke? Does the frontal cortex show normal metabolism?

Dynamic: Identify brain function

Neuroimaging Modalities
Radiography (X-Ray) Fluoroscopy (guided procedures) Angiography Diagnostic Interventional Myelography Ultrasound (US) Gray-Scale Color Doppler Duplex Magnetic Resonance (MR) MR Angiography/Venography (MRA/MRV) Diffusion and Diffusion Tensor MR Perfusion MR MR Spectroscopy

Functional MR (fMRI)
Nuclear Medicine SPECT PET

Computed Tomography (CT)

CT Angiography (CTA)
Perfusion CT CT Myelography

Radiography (X-Ray)

Static: X-Ray

X-ray tube projects through head Detector plate measures transmission of X-rays

Bone relatively opaque to X-rays Soft tissue relatively transparent

Useful for Angiography, looking for broken bones Poor for questions about grey vs white matter

Radiography (X-Ray)
Primarily used for spine: Trauma Degenerative Dz Post-op

Fluoroscopy (Real-Time X-Ray)

Fluoro-guided procedures:

Angiography Myelography

Static: Cerebral Angiography

Identifies arterial disease, aneurysms and AV malformations Radiopaque substance released into blood and followed through system Digital subtraction: computer development to improve contrast in pictures

Fluoroscopy (Real-Time X-Ray)

Digital Subtraction Angiography

Fluoroscopy (Real-Time X-Ray)

Myelography
Lumbar/cervical puncture

Inject contrast intrathecally with fluoroscopic guidance

Follow-up with post-myelo CT (CT myelogram)

Ultrasound

US transducer
carotid

Static: CT

Computerized Tomography (CT) or Computerized Axial Tomography (CAT) Looks at radiographic pictures taken in series across brain May be enhanced by use of compounds injected Excellent for distinguishing relationships and shifts and lesions

Ultrasound Gray Scale

Gray-scale image of carotid artery

Ultrasound Gray Scale

Plaque in ICA
Gray-scale image of carotid artery

Ultrasound - Color Doppler

Peak Systolic Velocity (cm/sec) 125 225 225 350 >350

ICA Stenosis (% diameter) 50 70 70 90 >90

Static: CT

Imaging technique that relies on X-rays Widely available Most (if not all) hospitals have CT Many clinics also have CT scanners CT shows body structures (bone and soft tissue) does not show function (metabolism)

CT or CAT scan (Computed Tomography)

Computed Tomography (CT)

Computed Tomography
A CT image is a pixel-by-pixel map of X-ray beam attenuation (essentially density) in Hounsfield Units (HU) HUwater = 0 Bright = hyperattenuating or hyperdense

Computed Tomography
Typical HU Values:
Air 1000 Fat 100 to 40 Water 0 Watery fluid (e.g. CSF) 020 White matter 2035 Gray matter 3040 Blood clot 5575 Calcification >150 Bone 1000 Metallic foreign body >1000

Brain

Computed Tomography

Computed Tomography

Computed Tomography

Computed Tomography

Computed Tomography

Scan axially stack and reslice in any plane

CT Angiography
1. Rapid IV contrast bolus

2. Dynamic scanning during arterial phase Neck: arch to skull base Head: circle of Willis
3. Advanced 2D and 3D Reconstructions: 2D multi-planar (sagittal, coronal) Volumerendered 3D recons

CT Angiography - Neck
Carotid
bifurcations

Vertebral arteries

Aortic arch

CT Angiography - Head
Circle of Willis

Vascular Malformations

Aneurysms

CT Angiography
3D Volume Rendering

CT Angiography
3D Volume Rendering

CT Perfusion
CBF MTT

CBV

Rapid Imaging During 1st Pass of Contrast Bolus Arterial phase:

Anterior cerebral artery

Venous phase:

Superior sagittal sinus

Perfusion Parameters Derived From Concentration-Time Curves

Bolus arrival

Vein

Artery

Perfusion Parameter Maps

Transit Time Blood Flow Blood Volume

CTA + Perfusion Example 1

48 YO W/ CONFUSION, IMPAIRED COGNITION AND LEG WEAKNESS

Dense MCA branch?

CTP

CBF

MTT 56.8 3.5

8.2

13.3

CBV 2.7

1.4

CT Myelography

CT Myelography

Static: CT

Is based on absorption of x-rays as they pass through the different parts of a patients body Depending on the amount absorbed in a particular tissue such as muscle or lung, a different amount of x-rays pass through and exit the body The amount of x-rays absorbed contributes to the radiation dose to the patient During conventional x-ray imaging, the exiting x-rays interact with a detection device (x-ray film or other image receptor) and provide a 2 dimensional image of the tissues within the patients body an x-ray produced photograph called a radiograph. CT uses the same principle but uses a rotating x-ray

Static: CT
Advantages of CT Very quick Good spatial resolution compared to metabolic imaging Newer CTs can scan perfusion Is widely available (cheap compared to MRI)

Disadvantages of CT Uses X-rays (radiation!) Cannot detect acute ischemic stroke Poor spatial resolution compared to MRI

Static: CT

What is CT used for?

CT is mainly used for bone scans (broken bones!), chest x-rays, and stroke imaging CT is very quick (1-5 minutes) and is optimal for detection of cerebral hemorrhage Usually does not detect acute ischemic stroke Patients who receive tPA always get a CT before administration to rule out hemorrhage

Static: CT
Abnormal
CT scan
Enhancement

Normal
Dense bone Air Fat Water Brain CT scan Bright Dark Dark Dark Gray

Infarct

Dark

Subacute

Bleed
Tumor

Bright
Dark

No
Yes

MS plaque

Dark

Acute

Computed Tomography
Parenchyma
Attenuation: High or Low?
High:
1. Blood, calcium 2. Less fluid, more tissue

Low:
1. Fat, air 2. More fluid, less tissue

Air Fat Water Watery fluid White matter Gray matter Blood clot Calcification Bone Metallic foreign body

1000 100 to 40 0 020 2035 3040 5575 >150 1000 >1000

Static: CT
Hemorrhage Infarct Tumor

CT scans are improving

Static: MRI

Magnetic Resonance Imaging

Not radiographic, analyzes response to radiofrequency signal Visualizes structures

Assessment Techniques MRI.

Magnetic Resonance (MR)

Hydrogen proton in H20

MRI

Magnetic Resonance
Transmitter Receiver

RF
RF = Radio Frequency

B0

COMPUTER

The first use of MRI on a human happened on July 3, 1977 at 4:45am. Dr Damadian and his post-graduate assistants, Doctors Lawrence Minkoff and Michael Goldsmith, made a MRI image of Larry Minkoffs chest. This scan was done using the very first MRI machine, known as Indomitable. The first scans of patients with cancer occurred in 1978. Indomitable can now be found in the Smithsonian Institute as a piece of pioneering medical history.

First Recorded Use of MRI

Dr Damadian and his assistants, Dr Minkoff and Goldsmith standing next to the Indomitable

The first ever Magnetic Resonance Image. This is an image of Dr Minkoffs Chest taken on July 3, 1977 at 4:45am

MRI revolves around the fact that the human body is primarily composed of fat and water. Both of which contain hydrogen atoms. The human body is roughly 63% hydrogen. MRI also uses the fact that the nuclei of some atoms behave like a magnet. Whilst there is no magnetic field external to our body the hydrogen atoms are not lined up in any particular order. When these atoms are subjected to a strong magnetic field, such as one created by an MRI machine, the nuclei align the axis of spin either with or against the direction of the magnetic field. In picture A the atoms have no external magnetic field acting upon it, therefore the alignment of the atoms is not uniform. In picture B however there is an external magnetic force acting upon the atoms causing them to line up uniformly either along or against the magnetic axis of B0

Principles of MRI

When the magnetic field applied is turned off, the atoms will return to their un-uniform state again. In doing this they release a certain radio frequency photon emission. These emissions are whats collected and can be turned into an image by a computer.

Principles of MRI (continued)

Simplified diagram of the components of an MRI system.

Shimmingrf coil

rf gradient coil

main magnet

main magnet

Transmit

Receive

Control Computer

The Magnet is Never Off!

Imaging Equipment

Common causes of accidents

Mechanical failures with radiology systems MR environment problems

Copyright 2007

Radiology Systems

Accidents result from

Heavy use Abuse Poor/inadequate maintenance

Copyright 2007

Mechanical Failures

Carriage supports Table Foot rest Falling parts Impacts Collisions (failure of anti-collision sensors

Copyright 2007

MR Environment Problems

Projectile effect Torque Burns Image artifacts Accessory device malfunctions

Copyright 2007

Projectile Effect

O2 cylinder

MR system

Copyright 2007

Projectiles we have seen:

Oxygen cylinders Chairs IV poles Ladder Scissors Infusion pumps Oscilloscope Pens Pillows Pulse oximeters Laundry Carts Sandbag Stethoscopes Hand tools Floor buffer Hair clips

Copyright 2007

Torque Problems

Magnetic implants

Aneurysm clips

Tiny magnetic particles or fragments Greater risk with highfield-strength systems (1.0 T)

Copyright 2007

Burns

Coiled or looped devices Pulse-oximeter sensors ECG electrodes Implantable infusion pumps Nitroglycerin patches Metal-containing tissue expanders Pacing electrodes Contact with bore walls or RF coils

Copyright 2007

Device Malfunctions
Static Field Effects on ECG

Note increase in the T-wave or STsegment amplitude.

Reference: Kaut-Roth, C. MRI Safety [online]. 1996. Available from Internet: http://www.t2star.com/safety_1/MR_Safety.pdf.

Copyright 2007

Device Malfunctions

Pacemakers and other implanted devices Electric motors Electronic circuits Magnetically attached device ECG waveforms Analog gauges/meters

Copyright 2007

Magnetic Resonance
Excited protons relax back to equilibrium

T2 T1

Relaxation rates depend on local molecular environment

Magnetic Resonance

T1

(w/ fat suppression)

T2

Magnetic Resonance
Tissue contrast in MR may be based on:
Proton density Water/fat/protein content Metabolic compounds (MR Spectroscopy)
e.g. Choline, creatine, N-acetylaspartate, lactate

Magnetic properties of specific molecules

e.g. Hemoglobin

Diffusion of water
Perfusion (capillary blood flow) Bulk flow (large vessels, CSF)

Magnetic Resonance
T1-Hyperintense (bright)
Fat and the 4 Ms

Fat (unless deliberately suppressed)

Methemoglobin (subacute hematoma) Mineral deposition (Ca, Mg, Mn, etc.) Melanin (melanoma) Mush (highly proteinaceous fluid) Contrast material (gadolinium)

T1-Hypointense (dark)
Water, paucity of mobile protons (air, cortical bone) High flow (e.g. arterial flow voids)

Magnetic Resonance
T2-Hyperintense (bright)
Water
T2 bright = more water and/or less tissue (T2 = H20)
e.g. fluid collections, edema, demyelination, gliosis, some tumors, et al (non-specific!!)

Fat (but usually suppressed by design)

T2-Hypointense (dark)
Some blood products (subacute hematoma)

Mineral deposition (Ca, Mg, Mn, etc.)

Paucity of water or mobile protons (air, cortical bone) High flow (e.g. arterial flow voids)

Magnetic Resonance

T1

(w/ fat suppression)

T2

Magnetic Resonance

Magnetic Resonance

Magnetic Resonance

Magnetic Resonance
Fat Suppression

Magnetic Resonance
Fluid Suppression

T2-weighted

T2-weighted FLuid Attenuated Inversion Recovery (FLAIR)

Magnetic Resonance
Fluid Suppression

T2-weighted

T2-weighted FLuid Attenuated Inversion Recovery (FLAIR)

Magnetic Resonance

Magnetic Resonance
Accentuating blood/calcium

T2

T2*

Magnetic Resonance
Cranial nerves

CN-7 CN-8 CN-5

FIESTA
High spatial resolution, high tissue-CSF contrast (T2 weighting)

Diffusion MR Imaging

NORMAL

CYTOTOXIC EDEMA

Diffusion MR Signal

Magnetic Resonance
Imaging Diffusion
Highly sensitive to acute ischemia

+ within a few hours!

No other imaging is more sensitive to acute ischemia!

Magnetic Resonance Angiography

Contiguous axial source images

reformatted to maximum intensity projections (MIP)

Multiple projections allow 3D-like display

Magnetic Resonance Angiography

MR Venogram Superior sagittal sinus thrombosis

Magnetic Resonance Angiography with Perfusion MR

MRA

Perfusion MR

IV Contrast in Neuroimaging
1. CT: Iodine-based (I is highly attenuating of X-ray beam) MRI: Gadolinium-based (Gd is a paramagnetic metal that hastens T1 relaxation of nearby water protons) 2. Normal blood-brain barrier keeps contrast out of brain! Enhancement implies BBB either leaky or non-existent

Remember: Some structures live outside the BBB!

IV Contrast in Neuroimaging
Enhancement:
1. 2. Vessels Meninges

pachy = dura
lepto = pia-arachnoid 3. Circumventricular organs (structures outside BBB)

Pineal gland
Pituitary gland Choroid plexus 4. Disrupted/leaky BBB

Some tumors
Inflammation Infarction

IV Contrast: Yes or No?

w/o contrast

with contrast

Congenital malformations Trauma R/O stroke R/O hemorrhage Hydrocephalus Dementia Epilepsy

Neoplasm Infection Vascular disease Inflammatory disease

Always best to provide detailed indication! Radiologist will protocol exam accordingly

MR vs. CT
CT
Advantages: Simpler, cheaper, more accessible Tolerated by claustrophobics No absolute contraindications Fewer pitfalls in interpretation Better than MR for bone detail Disadvantages: Advantages: Much broader palette of tissue contrasts (including functional and molecular) yields greater anatomic detail and more comprehensive analysis of pathology No ionizing radiation Direct multi-planar imaging IV contrast better tolerated

MR

Ionizing radiation
IV contrast complications Need recons for multi-planar Limited range of tissue contrasts

Disadvantages:
Higher cost, limited access Difficult for unstable patients Several absolute contraindications (cardiac pacer, some aneurysm clips, etc.)

Claustrophobics may need sedation

Image interpretation more challenging Lacks bone detail

MRI

Different types of MRI scan

T1 (anatomical): fast to acquire, excellent structural detail (e.g. white and gray matter). T2 (pathological): slower to acquire, therefore usually lower resolution than T1. Excellent for finding lesions.

T1

T2

Static: MRI
Abnormal
T1MRI
dark

T2MRI
bright

Normal
T1-MRI
dense bone
air

T2MRI
dark
dark

bright
dark

Infarct

Bleed
Tumor MS plaque

bright1
dark

bright1

fat
bright

bright

bright

water
dark bright

dark

bright

brain 1. Unless very fresh or very old.

gm=gray, wm=white

medium

Static: MRI

Infarct

T1

T2

Static: MRI

Bleed

T1

Low relative contrast hard to see on T2

T2

Static: MRI

Tumor

T1

T2

Static: MRI

Multiple-Sclerosis

T1

T2

Positron Emission Tomography (PET)

Physics of PET

Cherry, S. R. & Phelps, M. E. (1996) Imaging brain function with positron emission tomography. In A. W. Toga & J. C. Maxxiotta (Eds.), Brain Mapping: The Methods (pp. 191-221). Toronto, ON: Academic Press.

PET images - radioactive isotopes

FDG or F18 fluorodeoxyglucose

O15 Water

Dynamic: PET
Positron Emission Tomography (PET) Measures uptake of radioactively-tagged tracer. Often tracer is glucose to determine which tissues have highest energy use during activity to CT scans: PET is similar

CT scans measure X-ray transmission: which parts of the body block X-rays PET scans measure X-ray emissions: where is the tracer uptake?

Dynamic: PET Clinical uses

Tumor detection (increased metabolism) Decreased metabolism in the brain Can help distinguish between Alzheimer's disease, blood flow shortages, depression, or some other reason for dementia PET can localize the origin of seizure activity, guiding neurosurgery

PET

T2 MRI

Dynamic: PET Clinical uses

PET can tell if muscle tremor is Parkinson's disease or another of the "Movement" disorders. PET can look at brain tumor and reveal if it's benign or malignant. It is also widely used when recurrence is suspected to show whether structural change is tumor re-growth or merely scar tissue. PET can "map" the areas of the brain responsible for movement, speech, and other critical functions. This is a remarkable guide for surgeons who are performing delicate operations on different areas of the brain.

Dynamic: PET Disadvantages

Poor spatial resolution (compared to MRI) Can be used for functional imaging but because of spatial resolution very few researchers still use PET Much more expensive than CT Takes a long time. Therefore:

Not optimal for persons with acute condition needing immediate medical management Not for persons who have difficulty laying still for extended period of time

PET scans are improving

Dynamic: fMRI

Take rapid MRI scans that are sensitive to bloodoxygen level (T2* weighted images). Used to determine which parts of the brain are activated by different types of physical sensation or activity. By collecting repeated MRI scans while a subject is processing a specific task, it is possible to identify what regions of the subjects brain receive increased blood flow

T2* fMRI scan Scans entire brain every 3 sec

Dynamic: fMRI

We can use fMRI to examine recovery from brain injury and guide neurosurgery. We can also use fMRI to discover how the healthy brain functions. Analysis of a series of fMRI scans Shown on top of T1 scan

Sodium Amytal Infusion

Wada Test

Intracarotid injection decreases function in one hemisphere for 2-10 min. Can test function of remaining hemisphere separate from one receiving drug. Used early in epilepsy cases

Electroencephalography (EEG)

Measuring electrical potentials from electrodes placed on the scalp Can make comparisons of activity in various parts of the brain Comparison of different wave patterns to represent different physiological functioning Compares function over time

Measuring electrical activity

When neurons fire, they create electical dipoles. Neurons aligned perpendicular to cortical surface.

Event-Related Potential (ERP)

128 Channel Cap

Magnetoencephalography (MEG)

151 Channel MEG

MRI vs MEG

With EEG we measure rhythms of the brain:

EEG

Alpha 7-13 Hz: mostly posterior. It is brought out by closing the eyes and by relaxation, and abolished by thinking. It is the major rhythm seen in normal relaxed adults Beta >13 Hz: most evident frontally. It is accentuated by sedatives. It is the dominant rhythm in people who are alert or anxious or who have their eyes open Theta 3.5-7.5 Hz and is classed as "slow" activity. It is abnormal in awake adults but is perfectly normal in children upto 13 years and in sleep Delta <3 Hz. It tends to be the highest in amplitude. It is quite normal and is the dominant rhythm in infants up to one year and in stages 3 and 4 of sleep

Useful for measuring sleep

http://www.brown.edu/Departments/Clinical_Neurosciences/louis/eegfreq.html

Electromyography (EMG)

Measure electrical activity at the level of the muscle Can determine if muscle is receiving electrical stimulation Helpful in spinal injury cases and myoneural problems

Additional Procedures

Dichotic listening

Assesses cerebral dominance Individuals usually understand speech better with right ear as fibers cross to left hemisphere which is dominant for speech Two words presented simultaneously - one to each ear Person reports which word was processed Spinal Tap to determine the presence of infections in

Lumbar Puncture

Electrical stimulation, TMS

Guided electrode implant