NEURORADIOLOGY

dr. Farhan Anwary, Sp.Rad

Bagian/SMF Radiologi
FK Unpad / RS dr. Hasan Sadikin
Bandung
NEURORADIOLOGY (NEUROIMAGING)

Plain Film
CT Scan (Computed tomography)
MRI (Magnetic Resonance
Imaging)
Angiography / DSA (Digital
Subtraction Angiography)
Sonography / USG / Color Doppler
Nuclear Medicine
PLAIN FILM/CONVENTIONAL
RADIOLOGY

SKULL : - Lateral view
- Sella
- Straight posteroanterior view
- Caldwell view
- Towne view
- Basal (submentovertex) view
- Waters view

Normal, Radiographic, Anatomy
LATERAL VIEW

Sutures
Calvarium
Sella
Dorsum sellae
Sinus sphenoidalis
STRAIGHT POSTEROANTERIOR
VIEW

Coronal - lamdoid suture
Orbital roof, petrus ridge,
internal auditory canal,
cribriform plate - crista galli,
maxillary sinus, nasal cavity,
upper lateral rim orbita
CALDWELL VIEW

Lesser - greater wings
Foramen rotundum ( V2 )
Orbital rim
Zygoma - zygomaticofrontal
suture
Floor of anterior cranial fossa
Frontal sinus
TOWNE VIEW

Occipital, parietal, frontal
Sagital suture
Posterior clinoid processes -
dorsum sellae
Internal auditory canal
WATERS VIEW

Maxillary - frontal sinuses
Orbital margin -
zygomaticofrontal suture
Zygomatic process
Body, ramus, condyle,
coronoid process
BASAL (SUBMENTOVERTEX)
VIEW

Odontoid
Middle fossa
Foramen ovale ( V 3 )
Foramen spinosum ( mma )
Sphenoid sinus
I . SINGLE LUSCENT DEFECT IN
THE SKULL

DDX : Normal variant
Pacchionian
granulation
Parietal foramina
DDX : Abnormal solitary luscent skull
defect ( Help Me )
Hemangioma
Epidermoid, dermoid
Leptomeningeal cyst
Paget's : osteoporosis
circumscripta
Post surgical
Metastatic (solitary)
Eosinophilic granuloma
Encephalocele
II. MULTIPLE LUCENT DEFECTS
IN THE SKULL

DDX : - Metastases
- Myeloma
- Hystiocytocis
- Hyperparathyroidism
- Cushing's
- Osteomyelitis
- Radiation
III. INCREASED SKULL DENSITY

A. Diffuse increased skull density

DDX : - Osteopetrosis
- Hematologic; anemias,
myelofibrosis
- Fibrous dysplasia
- Paget's disease
- Acromegaly
- Metastasis
- Dilantin
- Hypervitaminosis D
B. Focal increased skull density

DDX : - Osteoma
- Hyperostosis frontalis
- Meningioma
- Fibrous dysplasia
- Paget's disease
- Metastasis
- Calcified cephalhematoma
IV. INTRACRANIAL CALCIFICATION
A. Physiologic can occur in

1. Pineal
2. Habenula
3. Basal ganglia
4. Choroid
5. Dura
B. Phatologic calcifications

1. Tumors
a. O1igodendriglioma (90%)
b. Craniopharyngioma (70%)
c. Ependymoma (60%)
d. Choroid plexus papilloma (25%)
e. Low-grade astrocytoma (20%)
f. Meningioma (10%)
g. Other (Dermoid, pineal tumor,
lipoma)
B. Phatologic calcifications

2. Infection : CMV, toxoplasmosis,
cysticercosis
3. Vascular :
a. Atherosclerotic disease
b. Aneurysm
c. Arteriovenous malformation
4. Pathologic basal ganglia
calcification
B. Phatologic calcifications

5. Neurocutaneous
syndromes
a. Neurofibromatosis
b. Sturge-Weber syndrome
c. Tuberous sclerosis

6. Post trauma
C. Basal Ganglia Calcifications

DDX :
Endocrine : hypothyroidism,
pseudohypoparathyroidism
Infectious : CMV, toxoplasmosis,
cysticercosis
Toxic/Anoxic : CO, lead, radiation
Congenital : Tuberosclerosis,
Fahr's disease
V. Large Sella

DDX :
Tumor : Adenoma,
craniopharyngioma, optic nerve
glioma
Aneurysm
Increase intracranial pressure
Empty sella
CEREBROVASCULAR DISEASE

I. Cerebral Infarction
a. Etiology
1. Atherosclerosis (large
vessels)
2. Atherosclerosis (small
vessels)
3. Hypoxia / anoxia
4. Dissection
CEREBROVASCULAR DISEASE
I. Cerebral Infarction
a. Etiology

5. Fibromuscular dysplasia
6. Vasculitis
7. Basal arteriovascular occlusiv disease
8. Venous thrombosis
9. Miscellaneous; vasospasm, trauma
b. Imaging in ischemia / infarction :

- Vascular distribution
- Evidence of cytotoxic edema
- Involvement of cortex
- Hemorrhagic transformation

c. IMAGING : CT, MR, MRA,
Angiography
II. Spontaneous Intracranial
Hematoma;
Intraparenchymal hematoma

DDX : Causes of intraparenchymal
hematoma
1. Aneurysm rupture
2. Arteriovenous malformation
rupture
3. Hypertension
4. Tumor

DDX : Causes of intraparenchymal
hematoma
5. Blood dyscrasia
6. Anticoagulant
7. Drug abuse
8. Infarct
9. Amyloid angiopathy
10. Idiopathic

III. Spontaneous Intracranial
Hemorrhage;
Subarachnoid and extra-axial
1. Subarachnoid hemorrhage (SAH)
2. Extra-axial hemorrhage (SDH, EDH)


IV. Intracranial Aneurysm
V. Cerebrovascular Malformations
1. Capillary telangiectasis
2. Cavernous angioma (hemangioma)
3. Venous angioma
4. Arteriovenous malformation (AVM)
5. Occult cerebrovascular malformation
(cryptic AVM)
6. Vein of galen aneurysm
CRANIAL TRAUMA

1. Imaging
Skull film, CT, MRI

2. Type of Injuries
a. Direct
b. Indirect
c. Skull fractures
3. Types of the Hemorrhages
a. Appearance of hemorrhage by
CT
b. Appearance MR
c. Extra axial hemorrhage
CRANIAL TRAUMA
Extra Axial Hemorrhage

1. Epidural hematomas
2. Sub dural hematomas
3. Sub arachnoid hemorrhage
(S.A.H)
4. Intra ventricular hemorrhage
5. Intra parenchymal hemorrhage
DDX : Parenchymal Hematoma

Aneurysm rupture
AVM rupture
Hypertension
Hemorrhagic infarct
Hemorrhagic tumor
Bleeding diathesis
Amyloid angiopathy
INTRACRANIAL MASSES

1. Radiografic Characteristic of Lesion
a. Intrinsic CT density
b. Contrast enhancement BBB
(ring, gyriform, homogenous)
c. Multiple lesions
d. MR appearance
DDX : Intracranial Mass
(TEACH )

Tumor
Edema
Abcess, AVM, aneurysm
Cyst
Hematoma
A. Primary Tumor

1. Glioma
a. Astrocytoma
b. Ependymoma
c. Oligodendroglioma
d. Ganglioglioma
2. Meningioma
3. Lymphoma

B. Metastatic Tumor
DIFFERENTIAL DIAGNOSIS BY LOCATION
DDX : Enhancement pattern of focal cerebral
parenchymal lesions
A. Cerebral parenchymal lesion
Ring : - Glioma
- Meta
- Abcess
- Resolving hematoma
- Resolving infarction
Homogenous :
- Lymphoma
- Aneurysm
DDX : Intraventicular Mass Lesion

Meningioma, Astrocytoma, Choroid
plexus papilloma, Colloid cyst, Meta,
Ependymoma, Subependymoma,
AVM, Oligo, Lymphoma
DDX : Pineal Region Mass

Germ cell tumor, Pineal cell
tumor
Germinoma, Pineoblastoma,
Teratoma, Glial cell tumor,
Dermoid, Epidermoid,
Choriocarcinoma, Meta
DDX : Juxta Sellar and Supra
Sellar

Adenoma
Craniopharyngioma
Aneurysm
Meningioma
Uncommon : Meta,
Arachnoid cyst, Glioma
DDX : CPA Mass
Acoustic neurinoma
Trigeminal neurinoma
Meningioma
Arachnoid cyst
Epidermoid
Aneurysm
Meta
INTRACRANIAL INFECTIONS
DISEASE

I. Focal Lesions
A. Pyogenic brain abcess
B. Atypical brain abcess
C. AIDS : Toxo, Lympho, TB,
Abcess
II. Encephalitis
Congenital : TORCH
Toxo, CMV, Rubella, Herpes

III. Meningitis
WHITE MATTER DISEASE

A. Demyelinating Diseases

DDX : - Primary : MS
- Viral
- Toxic and Metabolic
- Post therapy
- Vascular / SAE

B. Dysmyelinating Diseases
- Leucodystrophies


IMAGING OF THE SPINE
I. Approach
1. Primarily a bony lesion
2. Primarily a joint-space lesion
3. Primarily a lesion involving the soft
tissues with the neural canal or exit
foramina
4. Congenital abnormality may involve
dysplastic changes of both osseous and
neural components

II. Primarily an Osseous
Lesion

1. Primary bone tumor
2. Secondary bone tumor
3. Inflammatory bone disease
4. Hematologic or vascular
5. Trauma
6. Metabolic
7. Congenital anomaly
III. Primarily a Joint-space
Lesion

1. Degenerative disc disease
2. Trauma (iatrogenic)
3. Disc-space infection
IV. Primarily a Lesion Involving
Soft Tissues of Canal or
Foramina

1. Intramedullary
2. Intradural and
extramedullary
3. Extradural
V. Congenital Anomalies
1. Scoliosis
2. Vertebral anomalies
3. Dysraphism
4. Syrinx
5. Tumors
6. Neurofibromatosis
7. Spinal stenosis
dr. Farhan Anwary, Sp.Rad
TERIMA KASIH