Neuroscience

4.1.1
Neuroimaging

Nov. 9, 2015

Dr. Louie Gayao

OUTLINE
A.
B.
C.
D.
E.
F.
G.
H.

Radiologic Techniques
Plain Radiographs
CT Scan
Magnetic Resonance Imaging
Cerebral Arteriography
Ultrasonography
Technique Selection
Venous System

NEUROIMAGING

A. RADIOLOGIC TECHNIQUES
Two major Radiologic modalities in brain (and
meninges/coverings) evaluation:
o Anatomic Modalities- provide information
mostly of structural nature
Include plain films of the skull, computed tomography
(CT), magnetic resonance imaging (MRI), cerebral
arteriography, ultrasonography
o Functional Modalities- Single photon emission
computed tomography (SPECT), PCT imaging,
Perfusion Weighted
MRI, Diffusion weighted MRI imaging, functional MRI
(fMRI), MRS
o Gives info about brain perfusion or metabolism
Some techniques provide both anatomic and functional
info such as:
o Cerebral arteriography- depicts blood vessels
supplying the brain but also allows us to estimate
brain circulation time.
Ultrasonography of the carotid bifurcation- routine
sonogram of the carotid bifurcation gives anatomic data
when combined with Doppler data, readily provides info
about blood flow.
B. PLAIN RADIOGRAPHS
Bones of skull can block a large number of x-rays thereby
casting a white "shadow" on the x-ray film
Soft tissues such as scalp or brain cast little, if any
shadow on the film
Info about bones of the skull, no direct info about
intracranial contents
Indirect info about intracranial abnormalities can
sometimes be obtained from the skull plain radiograph
Largely replaced by CT/MRI
C. CT SCAN
Show fracture, intracranial abnormality that might require
treatment, computer generated cross sectional images
obtained from a rotating x-ray beam and detector system
Depict and differentiate between soft tissues, thus allowing
direct visualization of intracranial contents and
abnormalities associated with neurologic disease.
Consist of images adjusted to emphasize soft tissue detail
as well as images adjusted to visualize bony detail.
Cortical bone = white (High attenuation value or
Hounsfield unit)
Air within paranasal sinuses appears black (low
attenuation value)
Cerebral white matter has a slightly lower Hounsfield
number than does cerebral gray matter and consequently
appears slightly darker than gray matter in a head CT

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scan.
Intracranial pathologic condition can be either dark (low
attenuation) or bright (high attenuation) depending on
abnormality
Acute intracranial hemorrhage typically very bright
Acute cerebral infarction - low attenuation (black)
compared to normal brain because of edema
"light up" normal blood vessels, dural sinus as well as
pituitary gland, choroid plexus, or pineal gland.
Pathologic conditions that interrupt BBB also demonstrate
enhancement after contrast material administration.
CT Angiography (CTA) implemented into developed
stroke protocol exam.; Identifies location and extent of
large vessel occlusions, predict response to reperfusion
therapies ; recent application in screening evaluation of
blunt cerebrovascular injury including head injuries, basilar
skull fracture and cervical vertebral fracture ; accurate for
ICA dissections a d assessing stenoses (difficult
evaluation due to surrounding dense bone).
CT venography - for dural sinuses and veins, evaluate
dural venous sinus thrombosis, distinguish partial sinus
destruction from venous occlusion
D. MAGNETIC RESONANCE IMAGING
Visual display of nuclear magnetic resonance
Data collected principally from nuclei within body tissues
esp. within fat and water molecules
Useful in demonstrating shear lesions within brain,
assessing brain in remote head trauma.
Intrinsic tissue relaxation occurs by two major pathway
Longitudinal / T1 - fluid very dark, fat is bright ;
Transverse / T2 - fluid is very bright, fat dark
BOTH cortical bone and air are very dark on all imaging
sequence; Brain tissue intermediate intensity
MR Angiogram - first line studies for evaluating arterial
occlusion and screening of intracranial aneurysms.
Perfusion MR imaging - measure CBF at capillary level of
organ or tissue region; measures brain function.
Perfusion Weighted MRI - applications in evaluation if
diseases such as cerebral ischemia, reperfusion, brain
tumor, epilepsy, blood flow deficits in Alzheimers.
Functional MRI - brain mapping techniques, uses fast
imaging to depict regional cortical blood flow changes in
space or time; based on CBF and neuronal activity; used
presurgically and for provision of spatial resolution.
MRI spectroscopy - qualitative and quantitative info
about
brain metabolism and tissue composition
E. CEREBRAL ARTERIOGRAPHY
Water soluble contrast injected in femoral or brachial artery
(carotid or vertebral artery)
Gold standard for assessing vascular stenosis,
atherosclerosis, vasculitis, cerebral aneurysms.
Used in gray scale imaging and Doppler Effect evaluation of
carotid artery in atherosclerosis, vasospasm in
subarachnoid hemorrhage
Used intraoperatively to demonstrate spinal cord and
surrounding structures.
F. ULTRASONOGRAPHY
Diagnostic application of UTZ in the human body
Intracranial abnormalities in newborn and young infants

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UTZ

Cerebral
Arteriography

PET Scan

X
X
X

Complex partial
seizure
Congenital
anomaly
Craniocerebral
trauma, with skull
fracture &
intracranial
hemorrhage
Intracranial
hemorrhage

Internal Carotid and Vertebral Arteries - all originated

from the AORTA.

CAROTIDS
RIGHT
o Aorta Right Innominate (Brachiocephalic) artery Right
common carotid artery right external and internal carotid
arteries
LEFT
o Aortic arch Left common carotid left external and
internal carotid arteries
Note: Left Carotid directly from aortic arch, Right Carotid
from brachiocephalic/innominate.

Neurologic deficits
unexplained by CT

X
X

Infarct , Acute

Vascular Stenosis
Tumor

Skull fracture

Aneurysms
Vascular
malformations
Infection

Cerebral
Angiogram

Intracranial
abnormality
Subarachnoid
headache

DW MRI

Nonfocal headache

CT

MRI

G. TECHNIQUE SELECTION

X
X

In congenital anomaly, except cases of fusion of suture.

In Aneurysms, DW MRI can be done as first examination
on cases of intracranial masses.
Vascular malformations 1st test done is MRI or CT scan
In tumor, CT scan as supplement test.

External Carotid Arteries (ECA)

Supply the face and other parts of the face and major
portions of the cranium EXCEPT the brain.
Collateral branches of ECA that may take charge of
supplying blood to the brain if an obstruction or thrombus is
present:
Superficial Temporal a. - arising from facial arteries
and
preauricular arteries.
Internal Maxillary a. - gives off the middle meningeal
artery which passes through the foramen spinosum
forms small anastomoses inside the brain.
Ascending Pharyngeal a.
VERTEBRAL ARTERIES
RIGHT:
o Aortic arch Right Innominate artery Right
subclavian right vertebral artery
LEFT:
o Aortic arch Left subclavian left vertebral artery
i.e Left subclavian directly from aortic arch, and right
subclavian from innominate/brachiocephalic
ICA - DO NOT branch out externally but goes up into the skull
and branches out into: anterior choroidal, middle cerebral
artery,
anterior
cerebral
artery
and
posterior
communicating artery.
Removing the other parts of the head, ECA and ICA branches
will be exposed

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H. VENOUS SYSTEM

INTERNAL CAROTID ARTERIES

Located posterior to the ECA
Common carotid arteries (CCAs) bifurcate usually
opposite the upper border of the thyroid cartilage into the
internal carotid arteries (ICAs). ICAs travel behind the
pharynx
Segments:
Cervical segment - located along the entire neck
o Special Portion: Carotid Siphon
ICA forms an S-shaped structure in the (intra) petrous
and the (intra)cavernous portions.
Petrous segment - inside the petrous part of the
temporal bone
Cavernous segment - when the ICA enters the
cavernous portion of the brain
Clinoid segment - or supraclinoid segment, once the ICA
enters the supraclinoid portion.
o Ophthalmic artery - supplies the fundus (back of the eye
- orbit)

Drains about 70% of the cerebral blood volume

Intracranial veins are divided into: dural sinuses,
superficial and deep venous systems
Dural venous sinuses are trabeculated and are lined with
endothelial cells. Walls are fibrous wherein the outer and
inner layers are formed from the dura mater
The venous sinuses are situated in the junctions and
edges of the falx cerebri and tentorium cerebelli
The major sinuses
o Transverse sinus
o Superior Sagittal Sinus
o Confluence of sinuses
In the deep inferior portions of the brain: the cavernous
sinus (bilaterally) connected to the intracavernous sinus
where it drains the ophthalmic veins and other veins of
the face.

The ICA then penetrates the dura mater to give

off the following:
Posterior Communicating Artery/PCOMM - connect
the anterior circulation with the posterior circulation
Anterior choroidal artery (AChA) supplies medial portion
of
temporal lobe and part of basal ganglia (BG)
The ICA then forms a T- shaped structure which
separates into:
o ACA - anteriorly
MCA - lateral side

The intercranial veins from the superior sagittal sinus

receives blood from the major hemispheres of the brain
and drain into the confluence of sinuses, aka
Torcularherophili drains into the transverse sinus
bilaterally sigmoid sinus goes out of the cranium via
the jugular vein superior vena cava
PATHWAY: Inferior sagittal sinus deep venous drainage
which also follows the course of the falx cerebri and joins the

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internal cerebral vein (drains blood from the diencephalon)
posteriorly as the great cerebral vein of Galen forms the
straight sinus Torcula herophili (confluence of sinuses)
transverse sinus sigmoid sinus jugular vein
MR VENOGRAM - AP AND LATERAL VIEW

MR
Venogram,
AP view
Cerebral
Veins Superior
Sagittal Sinus
confluence of
sinuses
transverse sinus
sigmoid
sinus jugular
vein

MR
Venogram
, Lateral
view
Sagittal
sinus
inferior cerebral
sinus
great
cerebral
vein of
Galen
straight
sinus
confluence
of
sinuses

DEEP VENOUS DRAINAGE SYSTEM

Internal cerebral veins - lie in the roof of the third ventricle;
receives blood from thalamostriate veins (draining thalamus and
striatum), choroidal veins (choroid plexus of lateral ventricle),
and septal veins (from septum pellucidum)
Basal vein (of Rosenthal)- encircles cerebral crus; drains medial
and inferior surfaces of the frontal and temporal lobes, the
insular and opercular cortices, and regions of the hypothalamus
and midbrain.
Great vein of Galen located beneath the splenium of the
corpus callosum and receives the paired internal cerebral
veins, the two basal veins (of Rosenthal) and drainage from
the medial and inferior parts of occipital lobe

SUPERFICIAL VENOUS DRAINAGE SYSTEM

These are larger veins along the cerebral hemispheres that
anastomose with the sagittal sinus superiorly and with the
transverse sinus inferiorly
o Superficial middle cerebral vein - drain blood from the
lower hemispheres and drain towards the sagittal sinus
o Great anastomotic vein of Trolard - landmark during
surgery when opening a certain portion of the parietal
lobe (needed to be avoided to prevent hemorrhage inside
the brain); drain blood directly into the sagittal sinus
o Lesser anastomotic vein of Labbe - located along the
temporal side, landmark to be avoided during surgery to
prevent hemorrhage inside the brain; joins with middle
cerebral vein and drain blood directly into the transverse
sinus

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