Sie sind auf Seite 1von 69

Introduction to

Ilma Fiddiyanti.,SpRad.,Mkes
Neuroimaging Modalities
Radiography (X-Ray) Magnetic Resonance (MR)

Fluoroscopy (guided procedures) • MR Angiography/Venography

• Angiography
• Diffusion and Diffusion Tensor MR
• Diagnostic
• Perfusion MR
• Interventional
• MR Spectroscopy (MRS)
• Myelography
• Functional MR (fMRI)
Ultrasound (US)
Nuclear Medicine
• Gray-Scale
“Duplex” • Single Photon Emission Computed
• Color Doppler Tomography (SPECT)
Computed Tomography (CT) • Positron Emission Tomography (PET)
• CT Angiography (CTA)
• Perfusion CT
• CT Myelography
Radiography (X-Ray)
Radiography (X-Ray)

Primarily used for spine:

• Trauma
• Degenerative Dz
• Post-op
Fluoroscopy (Real-Time X-Ray)

Fluoro-guided procedures:
• Angiography
• Myelography
Fluoroscopy (Real-Time X-Ray)
Fluoroscopy (Real-Time X-Ray)
Digital Subtraction Angiography
Fluoroscopy (Real-Time X-Ray)
Digital Subtraction Angiography
Digital Subtraction Angiography

• Aneurysms, vascular malformations and fistulae

• Vessel stenosis, thrombosis, dissection, pseudoaneurysm
• Stenting, embolization, thrombolysis (mechanical and pharmacologic)

• Ability to intervene
• Time-resolved blood flow dynamics (arterial, capillary, venous phases)
• High spatial and temporal resolution

• Invasive, risk of vascular injury and stroke

• Iodinated contrast and ionizing radiation
Fluoroscopy (Real-Time X-Ray)

Lumbar or cervical puncture

Inject contrast intrathecally with

fluoroscopic guidance

Follow-up with post-myelo CT (CT


• Spinal stenosis, nerve root compression

• CSF leak
• MRI inadequate or contraindicated


• Defines extent of subarachnoid space, identifies spinal block


• Invasive, complications (CSF leak, headache, contrast reaction, etc.)

• Ionizing radiation and iodinated contrast
• Limited coverage

US transducer


• Carotid stenosis
• Vasospasm - Transcranial Doppler (TCD)
• Infant brain imaging (open fontanelle = acoustic window)


• Noninvasive, well-tolerated, readily available, low cost

• Quantitates blood velocity
• Reveals morphology (stability) of atheromatous plaques


• Severe stenosis may appear occluded

• Limited coverage, difficult through air/bone
• Operator dependent
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) ICA Stenosis (% diameter)

125 – 225 50 – 70
225 – 350 70 – 90
>350 >90
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 = “hyper-attenuating” or “hyper-dense”

Computed Tomography
Typical HU Values:

Air –1000
Fat –100 to –40
Water 0
Other fluids (e.g. CSF) 0–20
White matter 20–35
Gray matter 30–40
Blood clot 55–75
Calcification >150
Bone 1000
Metallic foreign body >1000
Computed Tomography
Attenuation: High or Low?

High: Low:
1. Blood, calcium 1. Fat, air
2. Less fluid / more tissue 2. More fluid / less tissue

Air –1000
Fat –100 to –40
Water 0
Other fluids 0–20
White matter 20–35
Gray matter 30–40
Blood clot 55–75
Calcification >150
Bone 1000
Metallic foreign body >1000
Computed Tomography

“Soft Tissue Window” “Bone Window”

Computed Tomography
Computed Tomography

Scan axially…
…stack and re-slice in
“2D Recons” any plane
CT Indications
• Skull and skull base, vertebrae

(trauma, bone lesions)

• Ventricles
(hydrocephalus, shunt placement)
• Intracranial masses, mass effects

(headache, N/V, visual symptoms, etc.)

• Hemorrhage, ischemia
(stroke, mental status change)
• Calcification

(lesion characterization)
Skull and skull base, vertebrae

Skull and skull base, vertebrae

Multiple Myeloma Osteoma


Intracranial masses, mass effects

Solid mass Cystic mass

Intracranial masses, mass effects

L hemisphere swelling Generalized swelling

Acute Hemorrhage

Intraparenchymal Subarachnoid Subdural Epidural

Acute Ischemia

Loss of gray-white distinction and swelling in known arterial territory


CT Angiography
1. Rapid IV contrast bolus

2. Dynamic scanning during arterial phase

3. Advanced 2D and 3D Reconstructions:

 2D multi-planar (sagittal, coronal)
 Volume–rendered 3D recons
CT Angiography - Head
CT Angiography - Head
Circle of Willis

Vascular Malformations

CT Angiography - Neck

Carotid Vertebral
bifurcations arteries

Aortic arch
CT Angiography
3D Volume Rendering
CT Angiography - Indications

• Atherosclerosis
• Thromboembolism
• Vascular dissection
• Aneurysms
• Vascular malformations
• Penetrating trauma
CT Perfusion CBV


Hemodynamic Parameters Derived From Concentration-Time Curves

Bolus Vein

Hemodynamic Parameter Maps

Transit Time (sec) Blood Flow Blood Volume

(mL/min/g) (mL/g)
CT Myelography
• Spinal CT immediately following conventional myelogram

• Cross-sectional view of spinal canal along with spinal cord

and nerve roots

• Assess spinal stenosis/nerve root compression

(e.g. disc herniation, vertebral fracture, neoplasm)
CT Myelography
CT Myelography
Magnetic Resonance (MR)

Hydrogen proton in MRI

water or fat
Magnetic Resonance Imaging
Magnetic Resonance Imaging

Transmitter Receiver


RF = Radio Frequency

magnetic COMPUTER
MRI Safety: The Magnet is Always On!
Magnetic Resonance Safety
MRI Safety Test:
Will it: Move? Torque? Get hot? Pass a current? Malfunction? Become a
projectile? Get stuck in scanner?

Typically safe*: Typically unsafe*:

• Orthopedic hardware • Cardiac pacemakers (and other
electrical devices)
• Surgical clips, staples, sutures (older
devices must be checked!) • Some older aneurysm clips
• Intravascular stents/filters • Metal fragments in orbit (1 case
• Oxygen tanks, carts, chairs, stools, IV poles,
gurneys, etc.
• Some cosmetics, tattoos, jewelry, hairpins,
• Pager, watch, wallet, ID badge, pen, keys,
pocketknife, etc.

* This is an incomplete list and there are many exceptions to every “rule”
When in doubt, check it out!
Magnetic Resonance
Excited protons relax back to equilibrium



Relaxation rates depend on local molecular environment

Magnetic Resonance

“T1-weighted” “T2-weighted”
w/ fat suppression
Magnetic Resonance
T1 T2

Arachnoid Cyst
Magnetic Resonance
T2 T2 w/ fat suppression
Magnetic Resonance
T2 T2 w/ fat suppression
Magnetic Resonance
T2 T2 w/ water suppression
Magnetic Resonance
Accentuating blood/calcium


T2 T2*
Diffusion MR Imaging


(Acute Ischemia)
Diffusion 
MR Signal 
Magnetic Resonance
Imaging Diffusion
Highly sensitive to acute

+ within a few hours!

No other imaging is more

sensitive to acute ischemia

although perfusion imaging reveals

hypoperfused tissue at risk for

Acute left MCA infarction

Magnetic Resonance Angiography

Axial “source” images… …reformatted to “maximum

intensity projections” (MIP)
Multiple projections allow 3D-like
No need for IV contrast! display
Time-Resolved MRA (TRICKS)

IV contrast bolus reveals temporal dynamics

Magnetic Resonance Angiography with
Perfusion MR

MRA Perfusion MR
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)
IV Contrast in Neuroimaging
1. CT: Iodine-based
Iodine is highly attenuating of X-ray beam (bright on CT)
MRI: Gadolinium-based
Gadolinium is a paramagnetic metal that hastens T1 relaxation of nearby
water protons (bright on T1-weighted images)

2. Tissue that gets brighter with IV contrast is said to “enhance” (Brightness, in

and of itself, is not enhancement!)

3. Enhancement reflects the vascularity of tissue, but…

The blood-brain barrier keeps IV contrast out of the brain!
Enhancement implies BBB is absent or dysfunctional
Remember: Some brain anatomy lives outside the BBB
IV Contrast in Neuroimaging

1. Vessels
2. Meninges
pachy = dura
lepto = pia-arachnoid
3. Circumventricular organs (structures
outside BBB)
Pineal gland
Pituitary gland
Choroid plexus
4. Absent/leaky BBB
Some tumors
T1 T1+C

Hemorrhagic melanoma metastasis

IV Contrast: Is it Indicated?
Typically not Typically yes

• Trauma • Neoplasm
• R/O hemorrhage • Infection
• Hydrocephalus • Vascular disease
• Dementia • Inflammatory disease
• Epilepsy

Always best to provide detailed indication!

Radiologist will protocol exam accordingly

MR vs. CT

Advantages: Advantages:
• Simpler, cheaper, more accessible • Much broader palette of tissue contrasts (including
functional and molecular) yields greater anatomic detail
• Tolerated by claustrophobics
and more comprehensive analysis of pathology
• No absolute contraindications
• No ionizing radiation
• Fewer pitfalls in interpretation
• Direct multi-planar imaging
• Better than MR for bone detail
• IV contrast better tolerated (in most pts.)
• Ionizing radiation
• Higher cost, limited access
• IV contrast complications
• Difficult for unstable patients
• Need recons for multi-planar
• Several absolute contraindications (cardiac pacer,
• Limited range of tissue contrasts some aneurysm clips, etc.)
• Claustrophobics may need sedation
• Image interpretation more challenging
• Lacks bone detail
Thank you