Beruflich Dokumente
Kultur Dokumente
DNT
Signal intensity Sharply demarcated
characteristics heterogeneous
(on
T2-weighted Unknown
image)
Contrast Rare
enhancement Common
Hemorrhage Excellent
Calcification
Prognosis
ntraventricular Masses
Tumor type Typical location
Central neurocytoma Lateral (attached to septum pellucidum)
Ependymoma Fourth, lateral
Subependymoma Lateral, fourth
Oligodendroglioma Lateral
Pilocytic astrocytoma Lateral, third, or fourth
Meningioma Lateral (atrium)
Choroid plexus tumor Lateral (atrium) or third in children, fourth in adults
Epidermoid Any ventricle
Subependymal giant Lateral
cell
astrocytoma Third
Colloid cyst Any ventricle
Arachnoid cyst
ntraventricular Masses
Tumor type Intensity characteristics Contrast enhancement
on T2-weighted images
Central neurocytoma Isointense to gray matter Usually dense
Ependymoma Heterogeneous Heterogeneous
Subependymoma Hyperintense to gray None
Oligodendroglioma matter
Pilocytic astrocytoma Heterogeneous Variable; irregular
Meningioma Hyperintense to gray Dense
matter
Choroid plexus tumor Dense
Isointense to gray matter
Epidermoid None
Heterogeneous
Subependymal giant Generally enhance
cell astrocytoma Slightly hyperintense to
CSF
Colloid cyst Limited enhancement at
Hyperintense to gray periphery
matter
Arachnoid cyst None
Hyperintense to gray
matter Isointense to CSF
Posterior Fossa Tumors in
Childhood
Juvenile pilocytic
astrocytoma
Medulloblastoma
neurologic
function
secondary
to
parenchymal
ischemia or
Main Etiologies for
Symptomatology of Stroke:
1. Cerebral Infarction
2. Intraparenchymal
Hemorrhage
3. Subarachnoid
Hemorrhage
Role of Imaging in Stroke:
1. Rule out hemorrhage
2. Rule other causes
of stroke syndrome
3. Help assess
etiology in known
ischemic infarction
The Normal Brain:
To sustain the normal
brain, a normal mean
regional cerebral blood
flow (rCBF) must be
maintained at about
54 (± 12 ml) /
100 g / min
The Normal Brain:
15 & 20 ml / 100
gm / min.,
ischemic brain injury
begins w/ loss of
neurologic function,
noted as flattening of
the
electroencephalogram
The Abnormal
Brain:
Blood flow values
below:
10 ml / 100 gm /
min.,
may lead to
infarction within a
few minutes.
The Ischemic Brain:
There are two ischemic changes
thresholds, one occurring at blood
flow range of 15-20 ml / 100 gm
/ min., resulting to loss of electrical
function and another one at 10ml /
100 gm / min. , resulting to loss of
cell polarizaton.
PENUMBRA
Heterogeneity in brain injury has been
documented in an infarcted zone.
Blood flow to an infarcted zone is said to
have:
A. a central region or core of very low
flow that results in rapid cell demise
and
B. a peripheral penumbra where decline
in flow is more moderate and cell
death is not immediate.
PENUMBRA
The penumbra is thought to
represent salvageable tissues that
may go on to infarction.
- Deep gray
matter
- Brain stem
- Deep hemispheric
Cardioembolic Infarction
- Relative stasis resulting to mural
thrombus, ex.: M.I., atrial fib.,
ventricular aneurysm
- Valvular heart disease
resulting to vegetation or from
prosthesis - Cardiac tumors
- Congenital HD,
ex.: right to left shunt
Watershed Infarction:
- Boundary zone infarct
- Internal carotid stenosis
or occlusion
- Systemic
hypotension - Embolic
events
Hemorrhagic Infarction:
- Hemorrhagic transformation results
to petechial hemorrhage or
frank hematoma -
Anticoagulant therapy
- Thrombolytic agents
- More common in cardioembolic strokes
- Larger cardioembolic strokes are
more likely to bleed
Temporal Evolution of Infarction on
CT Scan:
0 – 4 hrs. Normal to subtle hypodensity
± sulcal effacement
Days to Hypodensity
months/ yrs
Acute to Subacute Infarction
Changes:
1. Vasogenic Edema
that later on wanes
2. Enhancement -
(Luxury perfusion)
3. Petechial hemorrhage
Hypertensive Hemorrhage
In hypertensives, hyalinization within
the walls of small cerebral vessels
results in
microaneurysms
that are less than 1.0 mm in size,
(Charcot & Bouchard),
that tend to arise from perforating
vessels that will later on bleed.
Some of the Causes of ICH:
Hypertension
Amyloid Vasculopathy
Aneurysm
A-V malformation
Neoplasm
Coagulation disorders, e.g.
hemophilia
Aticoagulants
Vasculitis
Drug abuse e.g. cocaine
Trauma
Idiopathic
Hypertension accounts for 40-50%
of deaths from non-traumatic
hemorrhage in an autopsy series.
In young (less than 40 y/o)
normotensive patients, cause
remains unknown but cryptic AVM
is a suspect.
Why is there a need to measure
hemorrhage size?
Volume of the hemorrhage is a
strong indicator of the 30 day
survival of the patient.
Methods of measuring ICH
Volume:
A. Direct volume measurement in
the CT Scan system or in a
work station;
B. Planimetry
C. Application of the formula for
the sphere:
Volume = 4/3 π (r)3
D. ABC/2 method
Among different methods of volume
measurements, the direct volume
measurement in the CT scanner is the
most accurate but this would depend
on the cooperation of the facility
operators.
Once the patient data is deleted from
the memory file of the system, the
direct volume measurement can no
longer be applied on the data in the
hard copy (film).
In older model CT Scan where volume
measurement is not available, an
alternative method is possible by using
the area of the hemorrhage:
Volume in cubic cm =
Area x slice thickness (millimeters)
1000
ABC/2 Method:
Kothari, et. al., has developed a simple
bedside method of ICH volume
determination with the following
formula:
ICH volume = A x B x C
2
ABC/2 Method (continued):
Step 1: The largest dimension of the
hemorrhage is determined in the
series of CT slices, then the
largest diameter of the hematoma
is measured and labeled - A;
Step 2: On the same slice, the largest
diameter of hemorrhage 90o to A is
determined and labeled – B.
ABC/2 Method (continued):
Step 3: “C” or the cephalocaudal
dimention of the hemorrhage is
determined by comparing the rest
of the CT slices to the largest
hemorrhage on the scan.
If the hemorrhage area is 75 % of
the largest hemorrhage area =
one (1) slice for determining C;
ABC/2 Method (continued):
Step 3: If the area was 25 to 75% of the
slice where the hemorrhage was
largest, the slice is considered
as one-half a hemorrhage slice;
3 4
A
(2)
B
“1” slice
ABC/2 Method:
(A x B x C ) ÷ 2 = Volume in cc
A = 4.0 cm
B = 2.6 cm
C = 2.5 cm
(4.0 x 2.6 x 2.5) ÷ 2 = 13 cc
Actual computation directly done
in the CT scan = 13.3 cc
Reliability & Reproducibility of the ABC/2 Method of
Measuring Intraparenchymal Hemorrhage Volume
OxyHg in RBCs ≈
DeoxyHg in
≈,
RBCs
MetHg in RBCs
Extracellular
metHg
Ferritin and
≈,
hemosiderin
Acute Infarction findings in MRI:
1. Lesion in arterial distribution
2. High intensity in Proton
density or in T2 FLAIR
3. Gyral swelling / sulcal
effacement 4. Absent arterial flow void
5. Subcortical white matter
hypointensity 6. Intravascular
contrast enhancement
Diffusion weighted imaging:
-Signal attenuation is noted in areas of free
diffusion -
Signal intensity is increased in areas of
restricted diffusion with decrease in apparent
diffusion coefficient in brain tissue
- Decrease in
diffusion of water in early ischemia is due
to shift of water from extracellular to
intracellular