Neuroscience

4.1.2
Neuroimaging

Nov. 9, 2015

Dr. Louie Gayao

OUTLINE
A.
B.
C.

B. RADIOLOGIC NEUROANATOMY

Neuroradiologic History
Radiologic Neuroanatomy
Diagnostic Tests
1. Roentogram
2. Cranial Ultrasound
3. Cranial CT
4. Cranial CT Angiography
5. Cranial CT Perfusion

NEUROIMAGING
A. NEURORADIOLOGIC HISTORY
Neuroimaging
o Use of various techniques to directly or indirectly
image the structure or function of the nervous system
o Indications:
It follows patient history and neurologic
examination to investigate a patient who may
have neurologic disorder.
History
o Before the advances in radiology, direct visualization
of intracranial compartment was norm
o Exploratory
burrholes
Indications:
1. Rapidly deteriorating neurologic exam
2. Lack of scanning facilities
3. Inaccesible remote area
4. Patients unfit for transfer
Pag naghahanap at mageextract ng tumor, drill a hole on one
side; pag wala sa isa, sa kabila naman. Pag wala pa
rin,tigil ka na. Hanggang dun lang ang pwede mong gawin
o 1895- German physics professor discovered Xray. He
referred to radiation as X, to indicate it as ann
unknown type of radiation. Xray was noted at that
time to pass through human tissue but it could not
pass thrugh bone or metal
o 1927- Portugese physician Egas Moniz provided
contrasted xray cerebral angiography in order to
diagnose several kinds of nervous diease such as
tumors, artery disease and AVM.
o 1950s- Ultrasound gained in popularity
o 1970s- Development of CT Scan
o Eary 1980s- Development of MRI

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C. DIAGNOSTIC TESTS
Neuroimaging
Indications:
o Rule out structural disorder
o Recurring progressive headaches
o Focal slowing on EEG
o Comorbid seizures
o Persistent unilateral headaches
o Assure anxious patient or his relatives
1.

Roentogram

Photograph made with X-rays

SKULL X-RAY

Picture of bones surrounding the brain

Abnormal results may be due to: fracture, tumor,

erosion or decalcification of bone and movement of
the soft tissues inside the skull

AP view- Used to know the laterality of findings

Frontal and lateral view- Used to look for functional defects

Interpreted as hypodense (dark part) or hyperdense

(lighter part; Possibly water or air)

Metal is Hyperdense (compared to bone)

Bullet is very heavy (could migrate from one area to

another)

Intraoperative x-ray is performed to know if the area where

bullet is desired to be extracted is accessible or not

CERVICAL X-RAY

Locate the anterior vertebral line and posterior vertebral

line; assess if normally aligned and check for hernia

What to do if shoulder is not obstructing the view? Put

down the shoulder. Do not just tilt it. Tilting will obstruct the
reading, too.

3 Views needed: AP; Lateral; Open Mouth

Depressed fracture

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i. Prematurity
ii. Persistent large fontanel
iii. Synostosis ***
iv. Infection
v. Trauma
Limitations
i. Operator dependent-Di mo alam
view ng operator, mahirap i-orient
ang sarili
ii. Small acoustic window
iii. Cannot assess myelination
iv. Cerebellar lesions, infarcts
v. Small hemorrhages could be missed
vi. Deeper: blurred

ACOUSTIC WINDOWS

THORACIC X-RAY

An x-ray of the 12 chest bones/thoracic vertebrae. The

vertebra are separated by flat pads of cartilage called disks
that provide a cushion between the bones.

Used to evaluate bone injuries, cartilage loss, diseases of

the bone, tumors of the bone.

Test can detect bone spurs, deformities of the spine, disk

narrowing, dislocations, fractures, thinning of the bones
(osteoporosis), degeneration of vertebrae

2.

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Cranial Ultrasound
o Uses reflected sound waves to produce pictures
of the brain and the inner fluid chambers
(ventricles) through which the CSF flows.
o Indications

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ACOUSTIC WINDOWS - FONTANELLES

Anterior fontanelle (9-15 mos.); PATENT FROM 9 - 15
MOS., BY 15TH MO. NAGCLOCLOSE NA SIYA.
Posterior fontanelle (CLOSED BY 3 mos.)
TEMPORAL FONTANELLE - AROUND MGA 3 Y/O
Mastoid fontanelle (24 mos.)

From the anterior fontanelle, depends on the position of

your ultrasound probe you can direct it more frontally,
medial, posteriorly. You could adjust your probe to go
longitudinally so that you could see medially going laterally.
From anterior fontanelle, directed anteriorly, you would
expect to see your frontal lobes, interhemispheric fissure
and your orbital ridge.

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Cheaper than MRI
Faster testing time
Angiography: Vascular anomaly or
aneurysm detection (To check for
Intracranial Pressure)
Disadvantages

False negative results for small lesions

Radiation exposure

Allergic reaction (some people have allergic

reactions to the contrast being used or to
the iodinated contrast).

Pregnancy
is
a
contraindication
(contraindicated because of radiation effect,
they could place a radiation shield but as
much as possible they do reduce the
radiation exposure of the patient).

Creatinine monitoring (your kidney is the

one being used to excrete your contrast so
you have to monitor that, check before you
give your contrast).
Indications

Hemorrhage

Ischemia

Fractures

Calcifications

Dependent, kung hindi mo alam kung paano ang view ng

operator, it's very hard for you to orient yourself. But there
are standard views in doing cranial UTZ. So may c1
hanggang c7. May use silang lahat so somehow pag
sinabing c1 cut, alam mong it's more of anterior c2, c3,
c4, c5, c6, c7. Somehow may idea sila kung saan yung
location ng probe mo.
Here you can see the interhemispheric fissure, frontal
lobes. As you go deeper, the resolution of your structures
becomes more blurred already.
Here you can see lateral ventricles and your Cavum
Septum Pellucidum. Septum Pellucidum, iniisip niyo lang
is parang direct lang, isang septum lang siya. But your
septum sometimes there's a space in between that is
your cavum septum pellucidum.
Then this is the end of your caudate and putamen. Hindi
siya ganun kalinaw. So if Im gonna ask a question, it
would be nearer the probe to identify the structure.
This is the very easily identifiable, eto the third ventricle,
as you know beside your third ventricle would be your
thalamus.
Sylvian fissure very vague, lateral ventricle, corpus
callosum, you expect na nandito lang siya.
Interhemispheric fissure, frontal lobe. So it would depend
on the operator for you to have an orientation.

b. CONTRAST
o Iodinated contrast is injected to enhance imaging
o Indications

Neoplasms(TUMOR)

Vascular malformations(VASCULAR
ANOMALIES)

Meningitis(INFECTION)
**So you would see (the aforementioned) that would light up in
the scan.

Lateral view of your UTZ. Corpus callosum, cingulate

gyrus, third ventricle, yung iba medyo malabo na so it's
very hard to identify.

Two modalities for cranial CT:

o Plain Study
o Contrast Study
3.

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Cranial CT
a. PLAIN
o Advantages

Procedure of choice for acute hemorrhage

and skull fractures

This is somewhat a normal cranial CT scan. As you can

see there are some calcifications.

CT scan has three modalities:

(1) Contrast scans,
(2) Plain scan,
(3) Bone window
So these could replace your x-rays. If the patient is really
uncooperative and you could not do an x-ray, you could see
fractures already with your cranial ct.
You first have to identify what's normal. The sutures you might
consider fractures, so somehow you should know where are
the sutures and differentiate sutures from your fractures.

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Another view of your basal skull, so you have your mastoid,

your petrous, your clivus, simple squamous temporal bone,
greater wing of your sphenoid

Sylvian fissure?
Temporal horn of lateral ventricle?
Normally you don't get to see your temporal horn of
lateral ventricle but once you see it, may hydrocephalus
ka na.

What's the star?

Cistern, it's hypodense so most probably it contains fluid, most
probably CSF. Nandiyan yun basal cistern, carotid cistern,
suprasellar cistern, interpeduncular cistern nandiyan siya, so
yun yung basal cisterns natin.

By anatomy, you would expect there is a small line here.

So that's your coronal suture, frontal bone, parietal bone,
and occipital bone. So here it's not a fracture, ayan yung
lambda structure niyo.

Eh yung masayang singkit?

You can see your lateral ventricle, frontal horn, third
ventricle, lateral ventricle to third ventricle connected by
interventricular foramen (foramen of Monroe)

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HYPODENSE LESION?
The hypodense contains fluid so that's our 4th ventricle.
(doc also pointed out the 4th ventricle, cerebellum and
brainstem).

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ischemic stroke is understanding and identifying the infarct

core and the ischemic penumbra, as a patient with a small
core and a large penumbra is most likely to benefit from
reperfusion therapies.
Penumbra - water shed, salvageable by further medication.
In plain CT, you could not see the lesion yet. In perfusion
scan, you could see the infarcted area already.
The Three parameters typically used in determining these
two areas are:
o Mean Transit Time (MTT) or time to peak of the
deconvolved tissue residue function (Tmax)
o Cerebral blood flow (CBF)
o Cerebral blood volume (CBV)

Pineal gland calcified

In CT scan hypodense (dark); in MRI- it's hyperintense (dark)
4.

Cranial CT Angiography

Blue is Bad
T1: Fluid (CSF) is black
T2: Fluid (CSF is white
Better images in swelling

Employs rapid injection of iodinated contrast to visualized

intracranial vessels
Intracranial vessels are reconstructed after removal of bone
and parenchymal elements
3D RECONSTRUCTION USING CT ANGIOGRAPHY
You give large dose of contrast then do scan then the
computer will reconstruct based on the flow of the contrast.
The problem here is that manually nilang tinatanggal
yung bone structures and sometimes manually din
natatanggal yung ibang blood vessels.
Depending on how good the technician, if the technician
is good he will identify that as a pathology, aneursym,
small blood vessels but sometimes they just remove it,
binura lang nila kasama yung bone. So you could get
negative angiogram.
Advantages
o Ct angio readily available
o Rapid processing - important for unstable patients
Disadvantages
o More contrast used compared to conventional
angiogram
o Radiation
o User/processor dependent
o Could not assess flow pattern
5.

In MRI:
Hypointense dark area
Hyperintense light area

REFERENCES

From higher batch trans

th
From Textbook of Radiology and Imaging, Volume 2, 7
Ed. D. Sutton
From LANGE Basic Radiology
FROM LECTURE RECORDING

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Cranial CT Perfusion

The key to interpreting CT perfusion in the setting of acute

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